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Chap, Copyright No. 

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UNITED STATES OF AMERICA. 



DIAGNOSIS BY THE 
URINE 



OR 



THE PRACTICAL EXAMINATION OF URINE WITH 
SPECIAL REFERENCE TO DIAGNOSIS. 



ALLARD MEMMINGER, M.D, 

PROFESSOR OF CHEMISTRY, URINOLOGY, AND HYGIENE IN THE MEDICAL COLLEGE 

OF THE STATE OF SOUTH CAROLINA; VISITING PHYSICIAN IN THE 

CITY HOSPITAL OF CHARLESTON, ETC., ETC. 



Second JE&ition, ^Enlarges an£> IRevisefc* 
TOitb ITUustrations, 



PHILADELPHIA: 
P. BLAKISTON'S SON & CO., 

IOI2 WALNUT STREET. 
I8 99 . 



27359 



COPYRIGHT, I899, BY P. BLAKISTON'S SON & Co. 



TWO COPIES RECCiVEO. 



PRESS OF WM. F. FELL & CO , 

1220-24 Sansom Street, 

philadelphia. 






a. 



TO 

5tufcent8 of dfcefcicine anD practitioners at Xarge 

THIS LITTLE VOLUME IS DEDICATED. 

THE ATTEMPT AT SIMPLICITY OF ARRANGEMENT AND OF STYLE 

IT IS HOPED WILL COMMEND IT TO THEM, AND BE THE 

MEANS OF INCREASING THEIR KNOWLEDGE AND 

DIMINISHING THEIR LABOR IN THIS SPECIAL 

DEPARTMENT OF SCIENCE. 



PREFACE TO SECOND EDITION. 



The exhaustion of the first edition, together 
with the advance in science and knowledge 
gained by the author since the .publication of 
his work, rendered a thorough review of what 
was before written necessary. This has been 
carefully done, and the work now goes forth 
with many additions and radical changes which 
the later experience of the writer has found 
necessary so as to give more accurate results 
in diagnosis. 

A few remarks have been made as to the 
different kinds of tube-casts and the significance 
of their presence, but the main addition to the 
work has been in the chapter on the Dif- 
ferential Diagnosis of Chronic Bright' s Disease 
as Based on a Classification of the Normal 
Absolute, the Absolute, and the Relative 
Absolute of Solids and Urea. 

This chapter represents the views of the 



vi PREFACE TO SECOND EDITION. 

author, and it is sincerely hoped that the 
matter therein contained, and which has been 
gathered from a long and painstaking obser- 
vation of several years, will be of value to 
others, and likewise substantiated by those 
w r ho work in this field of science. Trusting, 
then, this edition will meet with as much favor 
from the profession as did the last, and that 
the views expressed, although possibly a little 
ultra to what is generally taught as to the 
significance of tube-casts, will yet be confirmed 
by future investigations, he has the pleasure of 
submitting to his critics what he has written. 

The Author. 

69 George Street, Charleston, South Carolina. 
February ^ i8gg. 



CONTENTS. 



PAGE 

Introduction, 9 

CHAPTER I. 

Physical Characteristics of Urine in Health, 11 

Amount, II 

Specific Gravity, 12 

Consistence, 16 

Color, 16 

Transparency and Odor, 1 7 

Reaction, 17 

CHAPTER II. 
Deviations in the Physical Characteristics of Urine in 

Disease, 18 

Amount, 18 

Specific Gravity, 19 

Color, 20 

Transparency and Odor, 22 

Reaction, 23 

CHAPTER III. 
Deviations in the Normal Chemic Composition of Urine 

in Disease, 26 

Urea, 26 

Estimation of Urea, 28 

Uric Acid, 32 

Chlorids, 35 

Phosphoric Acid, 37 

vii 



INTRODUCTION. 



The urine is the secretion of the kidneys, 
and, normally considered, is a solution of tissue 
which has undergone retrograde metamorpho- 
sis. The process by which this is brought 
about is a double one : filtration, which occurs 
chiefly in the Malpighian capsules of the kid- 
ney, and excretion, which is brought about by 
means of the epithelial lining of the tubules 
of the kidney. Although this is true for all 
practical purposes, still the lines are not so 
accurately defined as this, a certain though 
small proportion of the excretion taking place 
through the Malpighian tufts, and, conversely, 
a certain percentage of water being excreted 
along with the solids by means of the epithe- 
lium of the tubules. The average composition 
of this fluid is as follows : 

Total solids, 60 to 65 gm. 

Urea, 30 « 35 « 

9 



io DIAGNOSIS BY THE URINE. 

Uric acid, 0.5 to 0.8 gm 

Chlorids, 10 " 12 

Phosphoric acid, 2.5 " 3 

Earthy phosphates, . . . . 1 "1.3 

Sulphuric acid, 1.5 " 2.5 

Hippuric acid, °- 2 5" o-5 

Creatinin, 0.5 " 1 

In disease the urine, besides showing devia- 
tions in the normal constituents and physical 
characteristics, contains albumin, sugar, biliary 
coloring-matter, acids and fats, uroerythrin 
(red coloring-matter), ammonium sulphid, 
blood, leucin and tyrosin, carbonate and oxal- 
ate of calcium, carbonate of ammonium, cys- 
tin, xanthin, pus, epithelium, spermatozoa, and 
fungi. 



Diagnosis by the Urine. 



CHAPTER I. 

PHYSICAL CHARACTERISTICS OF URINE 
IN HEALTH. 

AMOUNT. 

The quantity of urine passed in twenty-four 
hours by one in health is dependent upon so 
many circumstances, at times controlled by 
mental, emotional, and physical causes, that 
it is hard to give an accurate norm. After 
most careful observations, however, extending 
over years, the author has arrived at the follow- 
ing estimate of quantities as fairly represent- 
ing, in a vast number of cases, a condition of 
health in the adult : 

1. A winter average of 1500 c.c. 

2. A winter occasional average of 2000 c.c, 
depending almost entirely on sudden cold 



12 DIAGNOSIS BY THE URINE. 

changes, accompanied frequently by moist, 
easterly winds. 

3. A winter minimum of 1200 c.c. 

4. A summer average of 1 100 c.c. 

5. A summer occasional average of 1500 c.c, 
depending much upon the same conditions as in 
winter. 

9. A summer minimum of 900 c.c. 

The average quantity, then, of urine passed 
by one in health in the twenty-four hours in 
winter is 1500 c.c, or 50 fluidounces. Most is 
passed in the afternoon, less in the morning, 
and least at night. Of course, the amount passed 
will be much influenced by the causes already 
mentioned, as also by the quantity of fluid taken 
into the system ; but the above is the general 
average for winter in health, and a variation of 
500 c.c less than the maximum, or 500 c.c 
more than the minimum, must be allowed, not 
constituting in this variation a condition of 
disease. 

SPECIFIC GRAVITY. 

The specific gravity of normal urine for the 
twenty-four hours has quite an extensive range ; 
and, as in the case of quantity, so have our 



PHYSICAL CHARACTERISTICS IN HEALTH. 13 

observations shown us that quite a different 
range is to be observed between the specific 
gravity of urine passed in winter and that 
passed in hot weather. 

Winter urine has a general average of 1.018, 
and varies, according to the quantity of water 
passed, from 1.013 to 1.022. 

Summer urine has a general average of 1.023, 
and varies, according to the quantity of water 
passed, from 1.017 to 1.030. 

The urine, too, of children shows very dif- 
ferent specific gravities in health and disease 
from that of the adult ; and, in the experience 
of the writer, has a normal specific gravity in 
winter varying from 1.008 to 1.012, and in 
summer, from 1.012 to 1.017. 

The water solids and urea will be found one- 
third less than in the adult ; therefore calcula- 
tions made as to the normal and relative abso- 
lutes of solids and urea, as indicating a state of 
health or disease, must be made with this 
understanding. 

In my experience, also, the urine of old men 
and old women shows a corresponding similarity 
to that of very young persons. 



14 



DIAGNOSIS BY THE URINE. 



The specific gravity is most easily obtained 
by means of the urinometer, as follows : 

Fill a small standing glass cylinder four-fifths 
full of the urine, remove all froth by means of 




Fig. i. — Urinometer. 



filter-paper, and place in cylinder the urine 
float (hydrometer), — do not allow the float to 
touch sides, — and read depth to w 7 hich hydrom- 
eter sinks ; the number so found, if urine has 



PHYSICAL CHARACTERISTICS IN HEALTH. 15 

temperature of 6o° to 62 F., represents the 
specific gravity. If the temperature is above or 
below, wait until it becomes 6o° or 62 , and 
then make your observations.* 

From the specific gravity we can approxi- 
mately, and for all usual clinical purposes, cal- 
culate the solids excreted in the twenty-four 
hours. The rule is as follows : Multiply the 
decimal of the specific gravity by 2.33 and the 
result will represent the weight of solids con- 
tained in 1000 c.c. of urine ; hence we can, if we 
have the quantity of urine passed in twenty- 
four hours, estimate the weight of solids con- 
tained in the whole. For example, patient passed 
3000 c.c. of urine of specific gravity 1.015 ; 
therefore 15 X 2.33 = 34.95 grams of solids 
contained in 1000 c.c. Consequently, to arrive 
at amount in 3000 c.c. we say : 

iooo : 3000 : : 34.95 : x 
x = 104.85 gm. 

If a more accurate determination of the solid 
matter is desired, the same is readily attained 
by evaporating a definite quantity of urine on 



* Hydrometers carrying temperature-chart on them can be procured 
of Messrs. Eimer & Amend, of New York. 



16 DIAGNOSIS BY THE URINE. 

the water-bath, drying at 21 2° F. the residue 
thus obtained, and then, by means of the chemic 
balance, ascertaining its weight. 



CONSISTENCE. 

Normal urine is a thin and easily dropping 
fluid, and only becomes viscid w r hen it has 
undergone or is undergoing some pathologic 
change. It foams on being shaken, but the 
same subsides and vanishes very soon after ; 
if, however, it contains sugar or albumin, the 
foam remains for a long time. 



COLOR. 

The color of normal urine is a bright amber 
or sherry-wine yellow if the entire quantity for 
the twenty-four hours (1500 c.c.) is taken ; if 
not, the color varies in consequence to the time 
of day taken — on rising in the morning it is 
darker, and during the day, and particularly 
after dinner, the tint is less strong. 



PHYSICAL CHARACTERISTICS IN HEALTH. 17 

TRANSPARENCY AND ODOR. 

Normal urine is always clear and transparent, 
and shows, on standing, a cloud of mucus ; this 
mucus is only mechanically suspended in the 
urine, and not in any wise dissolved ; the odor 
is sharp and slightly aromatic, and its cause is 
at present unknown. 



REACTION. 

The reaction of normal urine for the twenty- 
four hours is slightly acid, the same being 
caused by the presence of acid phosphates of 
the alkalies. To determine whether or not 
urine is acid, moisten a slip of blue litmus-paper 
with the secretion, and if it changes from blue 
to red, the urine is acid ; should the urine show 
an excessive degree of acidity, it is a sign that 
the urine is passing from a normal state to an 
abnormal one. Having now considered the 
general physical characteristics of normal urine, 
let us pass on to consider a deviation from 
these, and note those points which mark the 
beginning of disease in the urinary organs. 



CHAPTER II. 

DEVIATIONS IN THE PHYSICAL CHARACTERISTICS 
OF URINE IN DISEASE. 

AMOUNT. 

As has been previously said, the amount of 
urine passed in health in the twenty-four hours 
is about 1500 c.c.,or say 50 fluidounces. If the 
quantity is much increased, and habitually so, 
we have a condition of things known as poly- 
uria ; if, on the other hand, it is much dimin- 
ished, a condition known as oliguria ; and if 
entirely suppressed, anuria. 

Polyuria may be either physiologic or patho- 
logic ; in the first instance it is called urina 
potus (from excessive taking-in of fluids), 
and in the second hydruria or diabetes. To 
make a differential diagnosis in these cases, the 
total quantity of solids passed in the twenty- 
four hours is requisite, so this brings me at 
once to the consideration of the deviations in 

specific gravity which constitute disease. 

18 



PHYSICAL CHARACTERISTICS IN DISEASE. 19 

SPECIFIC GRAVITY. 

The specific gravity of normal urine, as has 
been said, varies much, being in winter at times 
1. 01 3, and again 1.022, but averaging about 
1. 01 8. As in the case, however, of the total quan- 
tity of urine passed in the twenty-four hours it 
was shown that an allowance, excessive or the 
reverse, to the amount of 500 c.c. must be made, 
so in the specific gravity a variation of a few 
degrees either way by itself indicates nothing ; 
when, however, a urine habitually falls below 
the winter minimum, or goes above its maxi- 
mum, it is an evidence in the first instance of 
a pathologic hydruria, and in the second of a 
condition known as polyuria. 

This latter condition is commonly called dia- 
betes, and is of two kinds : Diabetes insipidus, 
where the solids are all increased, but no sugar 
is present; when sugar is. found it is called dia- 
betes mellitus. As examples of these different 
kinds of- urine, I will say that in the first class 
of urines — the true pathologic hydrurias — we 
have a urine of low specific gravity, 1.002 or so, 
and large quantities of water, 4000 to 6000 c.c. 
On calculating the total solids, it will be found 



20 DIAGNOSIS BY THE URINE. 

that they are much diminished, whereas the 
water is in a corresponding degree increased 
above the normal. In the second class of urines 
the hydrometer shows a specific gravity of 1.025 
to 1.030, and the quantity of water is also con- 
siderably increased, being 1500 c.c. to 2500 c.c. 
in the twenty-four hours. In these urines, if no 
sugar is found, the increase in solids is most 
surely due to excessive quantity of urea or else 
to phosphoric acid. If the increase of solids is 
due to an increase of phosphates, it is called 
phosphaturia ; when, however, sugar is the 
cause of the increased specific gravity, it is 
called diabetes mellitus.* 



COLOR. 

Deviations in color mark the beginning of 
pathologic changes going on in the urinary 
organs. Colorless urines of low specific gravity 



* A condition known as chyluria, and simulating phosphatic diabetes, 
sometimes occurs ; the urine here is thick and heavy, and appears as a 
milky white liquid. It coagulates readily on being heated, as it con- 
tains much fibrin, and the coagulum does not dissolve on the addition 
of acetic acid, as would the phosphates ; this reaction, therefore, together 
with the presence of fat, renders the differential diagnosis in these cases 
easy. 



PHYSICAL CHARACTERISTICS IN DISEASE. 21 

and excessive increase of water — 4000 c.c. to 
6000 c.c. — evidence a neurotic affection. Color- 
less urines, again, with habitual low specific 
gravity, — 1.010 to 1.005, — but not necessarily 
an increase of water, point to atrophy of the 
kidney as the probable cause ; as the disease 
advances, however, the water increases beyond 
the normal. Urines also appear dark yellow- 
red, bright garnet-red, dark brown, and greenish- 
yellow. The color in dark yellow-red urines 
is due either to blood or else to a coloring- 
matter called uroerythrin. As the considera- 
tion of the morbid constituents found in 
urine is taken up separately, together with 
the consideration of the other colors named, I 
will defer this until later on, and will consider 
urines colored garnet-red, as this color is 
generally due to foreign vegetable coloring- 
matters. Take three drams of clear urine 
(filter, if not clear) ; add to the same in a test- 
tube ten drops of nitric acid (strong), and boil 
for a minute ; if the red is not due to pathologic 
changes in the urine the color will disappear, 
and on the addition of an alkali it will return, 
to be again dissolved when the urine is once 
more acidified by nitric acid and heated. 



22 DIAGNOSIS BY THE URINE. 

TRANSPARENCY AND ODOR. 

Normal urine being clear and transparent, 
with only floating particles of mucus, a urine 
deviating much from this is an indication of 
disease in the urinary organs. To determine 
this, take a portion of the twenty-four hours' 
urine, place in a glass cylinder, and stand same 
on piece of white paper ; by this we can deter- 
mine not only the amount of floating matter in 
the urine, but also, from the same specimen, the 
color, specific gravity, odor, and reaction. If 
the urine by this procedure appears thick and 
cloudy, it may be due simply to an insufficiency 
of water, or else to morbid changes. To differ- 
entiate these conditions, heat the urine in a test- 
tube, and if all dissolves, the turbidity was due 
to urates ; if, on heating, instead of clearing up 
it becomes more turbid, add a few drops of 
acetic acid, and if it now clears up, it is an 
evidence that the urine was too concentrated, 
and therefore the solids precipitated out. 

If, finally, the urine appears with the addition 
of acid and heat as it does without them, the 
turbidity is surely due to bladder or kidney 
detritus, and may therefrom be taken as an 
indication of disease. 



PHYSICAL CHARACTERISTICS IN DISEASE. 23 

REACTION. 

Normal human urine shows in the twenty- 
four hours' urine a slightly acid reaction ; if, 
however, the urine is taken at different periods 
of the day, it will be found that the acidity 
varies. Shortly after a meal the urine is 
slightly alkaline, but after a while it again 
rights itself. If the urine shows too decided 
an acid reaction it is abnormal, and marks 
either an excessive quantity of uric acid pres- 
ent or else an acid condition of the urine 
caused by free acid. This latter condition is 
easily determined by taking three drams of 
the twenty-four hours' urine (clear ; and, if not, 
filtered so as to make it so), placing it in a test- 
tube, and pouring into it one-half the quantity 
of a strong solution of the hyposulphite of 
sodium. If free acid be present, a turbidity 
immediately forms whose density is in propor- 
tion to the quantity of acid present. This re- 
action is caused by the precipitation of sulphur, 
the free acid having united with the sodium of 
the salt. 

The reaction, again, of urine may deviate 
in the opposite direction, constituting an alka- 



24 DIAGNOSIS BY THE URINE. 

line urine, and therefore indicating disease. 
There are two ways in which the urine may 
become alkaline, and it is very important, from 
a clinical standpoint, to name and understand 
them. The first is from fixed alkali and the 
second from volatile (carbonate of ammonia). 

Both forms of alkaline urine change red 
litmus-paper to blue on being moistened ; but 
in the case of fixed alkali, litmus-paper, on be- 
ing dried, does not regain its red color, whereas 
in the case of urine rendered alkaline from 
volatile alkali, the red litmus-paper regains its 
color on being dried. Urine showing the pres- 
ence of volatile alkali is always an evidence 
of disease (inflammation) of some part of the 
genito-urinary apparatus. 

If there be both fixed and volatile alkali 
present in the urine, the above test will give a 
negative result ; so important, however, is it for 
us to know whether or not volatile alkali is 
present, and therefore if inflammation is to be 
excluded, that we proceed as follows : Place 
ioo c.c. of the urine in a glass flask, to which is 
fitted a cork; on inserting the cork, allow a slip 
of moistened red litmus-paper to be placed 
against its side and extending down into the 



PHYSICAL CHARACTERISTICS IN DISEASE. 25 

flask, but not reaching into the urine ; heat 
the flask gently (do not boil), and if any carbon- 
ate of ammonia is present, the red litmus-paper 
will immediately turn blue. I suppose it is need- 
less for me to caution that this test must always 
be applied to fresh urine. 

Urines alkaline from fixed alkali generally 
effervesce on the addition of an acid, and though 
not indicating any particular derangement of 
the kidneys, are usually met with in enfeebled 
conditions of the body in which the respiratory 
act is performed with difficulty, and thus car- 
bonic acid is allowed to accumulate in the 
system ; also whenever the bile is diminished, 
or when there is a tendency to fermentative 
changes in the stomach or intestines. The 
dyspepsia which accompanies this kind of urine 
is attended with great depression of spirits ; 
flatulence is marked, the bowels confined, and 
the skin dark and sallow, showing evident 
derangement of the liver. 



CHAPTER III. 

DEVIATIONS IN THE NORMAL CHEMIC COM- 
POSITION OF URINE IN DISEASE. 

UREA. 

From a clinical standpoint, of all the normal 
constituents found in human urine we need 
only consider urea, uric acid, chlorids, and phos- 
phates of the alkalies and alkaline earths. Urea 
is the main solid which is passed in the urine, 
and averages from thirty to thirty-five grams 
(460 to 540 grs.) in the twenty-four hours. 
It is a diureid, and has the formula CON 2 H 4 . 

The quantity of urea excreted from the body 
in the twenty-four hours is much influenced by : 
(1) The amount of nitrogenous food supplied 
the system ; (2) amount of active exercise taken 
during the day ; and (3) the quantity of water 
drunk. If the three indications are all met, 
then urea increases very much in the urine. 
If, however, the amount increases and the three 

conditions mentioned are not given, why then 

26 



NORMAL CIIEMIC COMPOSITION IN DISEASE. 27 

the increase is an approximate evidence of the 
waste of the system. This takes place in all 
fevers and wasting diseases, and as long as the 
liver and kidneys remain intact, the former to 
manufacture and the latter to convey away 
retrograde tissue products, why then the esti- 
mate from day to day of the urea in the urine 
will be a pretty fair approximate estimate of the 
wearing away of tissue, and consequently of 
the loss of vital force. When urea, instead of 
being increased, is found to have decreased, 
it is then an evidence of either a diseased 
condition of the liver or kidneys. It is sur- 
prising to see, however, how low the urea 
finally runs in some cases before the fatal hour 
arrives. I have notes of a case treated for two 
months, and on no occasion during this time 
was there more passed than 13.52 grams in 
the twenty-four hours. We can safely say, 
therefore, that when urea in the urine of the 
twenty-four hours habitually falls below twenty 
grams in the case of an adult of active pur- 
suits and well-nourished body, we should sus- 
pect disease of the liver or else of the kidneys. 



28 DIAGNOSIS BY THE URINE. 

ESTIMATION OF UREA. 

The manner in which the estimation of urea 
is made is very simple and sufficiently accurate 
for clinical purposes. It is founded on the 
decomposition of urea by the action of such an 
agent as the hypobromite of soda : 

H 4 CON 2 + 3NaBrO = N 2 + C0 2 + 2H 2 + 3NaBr. 

The results would be a little low if urine 
contained urea alone, but since we find in it 
also uric acid, urates, and kreatinin, these, in 
giving up their nitrogen, make up for the loss, 
and thus nicely counterbalance this source of 
error. The manipulation of the process is as 
follows : We advise for use the most excellent 
ureometer designed by Dr. Charles Doremus, 
of New York, to whom, allow me to say, the 
profession owes a debt of gratitude for mak- 
ing so simple a process which has heretofore 
been so the reverse. These ureometers are 
graduated according to the French and English 
systems, respectively ; the manipulation with 
either is the same, but the calculations being 
different, I deem it best to describe the pro- 
cedure with each. 



NORMAL CHEMIC COMPOSITION IN DISEASE. 29 

1. Make a solution of sodium hydrate, ioo 
grams to 250 c.c. of distilled water. Keep this 
in bottle with rubber stopper. 

2. Make solution of hypobromite by adding 
one c.c. of bromin to ten c.c. of sodium hydrate 




Fig. 2. — Ureometer of Dr. Doremus. 



solution and diluting with ten c.c. of distilled 
water. 

It is convenient, instead of making this solu- 
tion previously (which does not keep long), 
to pour directly into the ureometer the sodium 



30 DIAGNOSIS BY THE URINE. 

hydrate solution until the liquid rises to the mark 
" = ", which is on each ureometer; by means, 
now, of a little nipple pipette, which goes with 
each set, measure out one c.c. of bromin, add 
this to the hydrate solution, and, after the bro- 
min has all gone into solution, dilute by pouring 
in water so as to fill the long arm and bend of 
the ureometer ; see, now, that the instrument is 
full, and thoroughly luted at the bend in the 
arm, — which is easily attained by tilting and then 
raising again until all air has been expelled, — 
and you have a thorough and complete mix- 
ture. 

The instrument is now in condition for your 
test, and the remarks made are true for the 
English as well as for the French instrument I 
am describing. 

Draw up by means of the pipette one c.c. of 
urine to be tested ; if the urine contains much 
albumin, free it of the same by heating, but not 
boiling ; if the quantity, however, is small, dis- 
regard it, and pass the pipette into the ureom- 
eter as far as the bend, and compress the 
rubber on end of pipette, thereby causing urine 
to ascend in hypobromite slow T ly; on so doing, 
there is great disengagement of gas (carbonic 



NORMAL CHEMIC COMPOSITION IN DISEASE. 31 

acid and nitrogen), and after the disturbance is 
over and several minutes are allowed to elapse, 
the volume of nitrogen may be read, as the 
column of liquid in the ureometer will be de- 
pressed just in proportion to the quantity of 
evolved gas, the carbonic acid gas being all 
absorbed by the hydrate of sodium. Each 
division mark on the ureometer indicates o.ooi 
gram of urea in one c.c. of urine. The quantity, 
therefore, of urea voided in the tw r enty-four 
hours is ascertained by multiplying the result of 
the test by the number of cubic centimeters of 
urine passed during that period. When the 
English ureometer is used, — divided, as it is, 
into grains, — the solutions are prepared and 
calculations made as follows : 

1. Make a solution of sodium hydrate, six 
ounces to the pint of distilled water ; keep this 
in bottle with rubber stopper. 

2. Make solution of hypobromite of sodium 
as previously described, and proceed exactly in 
the same way with the urine, etc. 

Each division on this ureometer indicates one 
grain of urea in one fluidounce of urine ; the 
quantity, therefore, of urea voided in the twenty- 
four hours is ascertained by multiplying the 



32 DIAGNOSIS BY THE URINE. 

result of the test by the number of ounces of 
urine passed during that period. 



URIC ACID. 

Uric acid is found only in small quantity in 
human urine, and when occurring in excessive 
amounts, its great insolubility in water causes it 
at once to crystallize out. This, unfortunately, 
frequently takes place in the kidneys, and thus 
concretions are lodged there which form foci of 
irritation, and finally, if allowed to continue, 
eventuate in one or other of the chronic forms 
of nephritis. 

Uric acid, also in union with sodium, potas- 
sium, and calcium, is often found in large quan- 
tities in urine, principally, we may say, in the 
beginning 1 Q f fevers and in all conditions in 
which the system is subjected either to a higher 
temperature for a short time, or else to a lower 
temperature for a longer period. Along with 
these urates is precipitated a coloring-matter, 
called uroerythrin ; this coloring-matter is red, 
and gives to uric acid and urate deposits a rosy- 
red tint — the so-called brick-dust deposit, so 
often observed in the pot de chambre in the 



NORMAL CHEMIC COMPOSITION IN DISEASE. 



33 



morning. If this deposit habitually occurs in the 
urine of persons not suffering from fever, it is a 
sign that the liver is at fault, and that the gouty 
or rheumatic gout diathesis is being established. 




Fig. 3. — Forms of Uric-acid Crystals. 
1. Rhombic plates. 2. Whetstone forms. 3. Quadrate forms. 4, 5. Prolonged 
into points. 6, 8. Rosettes. 7. Pointed bundles. 9. Barrel forms precipi- 
tated by added hydrochloric acid to urine. 



The presence of uroerythrin, uric acid, and 
urates is most easily ascertained. 

If these are present, the urine will be turbid, 
the urates will clear up on being heated, and 



34 DIAGNOSIS BY THE URINE. 

the uric acid will be dissolved if to the sedi- 
ment is added an alkali. To determine the 
presence of uroerythrin, take three drams of 
urine, place in a test-tube, add one to three 
drops of a solution of the acetate of lead, and 
if it is present, a precipitate of a rosy pink (flesh 
colored) will immediately fall. When uric acid 
occurs in abnormal amounts, it will be found, 
if the case is one of true lithemia, that all the 
other solids are diminished ; this state of things 
points strongly to grave diseases of the liver, 
acute yellow atrophy, cirrhosis, and cancer. If 
the urine for the twenty-four hours is near the 
normal amount, and uric acid crystallizes out 
a short time after standing, it is in abnormal 
quantity. Its detection is readily made in the 
following manner : Filter, if the urine is not 
clear, 100 c.c. ; acidify with ten c.c. of strong 
hydrochloric acid, allow it to stand, and after 
twelve hours uric acid will be found crystallized, 
and can be verified by either the microscope or 
else by the murexid test, which is performed 
as follows : Take a few of the crystals ; place on 
a watch-glass, add a few drops of nitric acid, 
and apply heat gently ; after thus attaining 
solution of the uric acid, dry carefully over the 



NORMAL CHEMIC COMPOSITION IN DISEASE. 35 

flame, and to the dry and cool mass add a few 
drops of ammonia ; if the crystals be uric acid, 
a most magnificent purple color will rapidly 
spread over the touched mass. 



CHLORIDS. 

In the urine of adults the chlorids consist 
almost entirely of chlorid of sodium, and the 
average quantity passed in twenty-four hours 
is between twelve and thirteen grams ; con- 
sequently it ranks next to urea as the prin- 
cipal constituent in urine. The quantity of 
chlorids present is subject, as with the other 
constituents, to fluctuations ; when, however, the 
average falls much below the figures just given, 
it is a sign of disease of the kidneys, or else of 
the final stage of some lung trouble or con- 
tinued fever. Whenever, in pneumonia, the 
chlorids leave the urine, the case must be 
regarded as very serious. In cases of chronic 
nephritis the regular and habitual falling-off of 
chlorid of sodium in the urine gives to the case 
a serious and grave aspect. The chlorids are 
not increased in pathologic urines, but are 



36 DIAGNOSIS BY THE URINE. 

sometimes found in larger quantities than 
usual when a salt diet is instituted. 

To determine whether they are in normal or 
diminished quantity, take two ounces of urine, 
filter if not perfectly clear, and if albumin is 
present heat with nitric acid and filter. Take 
the filtrate in this case, or, if albumin is not 
present, the clear urine, and acidify with nitric 
acid ; add to it four drops of a solution of 
nitrate of silver, — strength one part AgN0 3 to 
eight parts H 2 0, — and if chlorids are in normal 
quantity {y 2 of one to one per cent.) thick 
curdy masses of chlorid of silver (AgCl) im- 
mediately fall to the bottom of the test- 
glass. If, on the other hand, the urine con- 
tains a small quantity of chlorid, — say \ to -^ 
of one per cent., — the solution (urine, etc.), 
after the addition of the silver nitrate, shows 
only a cloud, and instead of the thick masses 
falling to the bottom, which do not mix readily 
with the urine, we have a solution of milky and 
turbid appearance. 



NORMAL CHEMIC COMPOSITION IN DISEASE. 37 

PHOSPHORIC ACID. 

The amount of phosphoric acid passing from 
the system in the course of twenty-four hours 
is, as we have said, 2.5 to 3.0 grams, and is 
distributed among the bases — lime, magnesia, 
soda, and potassa. Two- thirds are in combina- 
tion with the oxids of the alkalies, and the 
remaining one-third in union with the oxids of 
the alkaline earths. The alkaline phosphates 
are extremely soluble and are never deposited 
from the urine ; on the other hand, the earthy 
phosphates are only held in solution by the 
acid of the urine, and so soon as this is changed 
to a neutral or alkaline state a deposition 
takes place. To approximately determine the 
quantity of phosphoric acid in the urine : esti- 
mate, by rule already given, the total quantity 
of solids in the urine, expressed in grams ; 
then by the hypobromite method the total 
quantity of urea, expressed also in grams ; to 
this add eighteen grams, and subtract the same 
from the total solids, and the quotient divided 
by four will give the approximate quantity of 
phosphoric acid (P 2 O s ) passing from the body. 
Thus, for example, the total quantity of solids 



38 DIAGNOSIS BY THE URINE. 

found in a certain specimen of urine was 89 
grams, the quantity of urea was found to be 32 
grams, hence, 32 + 18 = 50, therefore, 89 — 
50 = 39, which divided by 4 gives 9.75 grams 
as the daily elimination of phosphoric acid in 
this case. This condition is known as phosphat- 
uria or phosphatic diabetes, and as much as 8, 
10, or 12 grams of phosphoric acid pass away in 
the twenty-four hours. Urines of this class re- 
semble closely the urine of diabetes mellitus — 
high specific gravity ; usually a normal quantity 
of water ; acid reaction, and an excessive or 
normal quantity of urea. Should, then, a urine 
show these characteristics, and the approxi- 
mate quantitative test for phosphates, as just 
explained, show their excessive amount, an 
accurate gravimetric determination of the 
phosphoric acid should be made. To this end 
measure out 50 c.c. of clear urine ; if albumin 
is present, precipitate out by nitric acid and 
take filtrate. Supposing, therefore, we have 
50 c.c. of clear urine : add to it 50 c.c. of strong 
sulphuric acid and 100 c.c. of water, boil in a 
beaker for a few minutes and then add a tea- 
spoonful of the nitrate of ammonia (in crystals) ; 
while still hot add a nitric-acid solution of 



NORMAL CHEMIC COMPOSITION IN DISEASE. 39 

molybdate of ammonia, adding this in excess ; 
stir well, boil a few minutes, and cast on a 
tarred (weighed) filter paper. Wash yellow 
precipitate two or three times with molybdate 
of ammonia solution; dry at 21 2° F. in a 
steam oven, and weigh precipitate and paper ; 
deduct weight of latter from former (precipitate 
and paper), and the result will give the weight 
of the precipitate of the phosphomolybdate of 
ammonia; this multiplied by 3.142 gives the 
equivalent quantity of phosphoric acid, which 
in our case represents the quantity in 50 c.c. of 
urine. To find, therefore, the quantity passed 
in the twenty-four hours is but a simple calcu- 
lation ; for example : 

Amount of urine passed in the twenty-four 
hours was 2000 c.c. ; 50 c.c. were taken for 
analysis, and the absolute quantity of phos- 
phoric acid (P 2 5 ) in the phosphomolybdate of 
ammonia precipitate was found to be 0.25 
grams ; consequently, to arrive at the quantity 
passed in twenty-four hours we say : 

50 : 0.25 : : 2000 : x 
x = 10.00 grams (P 2 5 ). 

The nitric-acid solution of molybdate of 
ammonia has the following composition : 



40 DIAGNOSIS BY THE URINE. 

Molybdate of ammonia, io gm. 

Solution ammonia, specific gravity 960, . . 40 c.c. 

Strong nitric acid, 80 c.c. 

Water, 80 c.c. 

Dissolve the salt in the ammonia by the aid 
of heat, then pour the solution into the nitric 
acid and water, which have been previously 
mixed together. 



CHAPTER IV. 

MORBID PRODUCTS IN THE URINE IN DISEASE. 

ALBUMIN. 

Albumin, which has an approximate compo- 
sition of oxygen, 22 per cent; carbon, 53; 
nitrogen, 16; hydrogen, 7; sulphur, 2, when 
found in the urine habitually with a diminished 
specific gravity, is an tin/ailing evidence of 
disease. True, we now and then meet with 
albumin in the urine of those in health ; even 
here, however, its appearance is only occasional, 
its quantity small, and never attended with 
habitual diminished specific gravity, as is the 
case in organic disease of the kidneys : this 
consideration, then, of the specific gravity be- 
comes, when albumin is present, and even when 
not, an all-important factor in making a differ- 
ential diagnosis. 

The detection of albumin is easily made as 
follows : 

(a) Tests Without Heat.— No. /. Acetic 

41 



42 DIAGNOSIS BY THE URINE. 

Acid and Ferrocyanid of Potassium Test. — 
This test, when executed in the manner laid 
down in this book, will be found to be most 
delicate, accurate, and reliable, and will, when 
albumin is present, show it and it alone. The 
presence of the ferrocyanid of potassium pre- 
vents the precipitation of mucin with the acetic 
acid, and, again, in the experience of the author, 
neither peptone, albumose, alkaloids, nor urates 
are at all affected by it. 

The test is applied as follows : Three c.c. of 
acetic acid, specific gravity 1.04 to 1.045, * s 
mixed with seven c.c. of a solution of the ferro- 
cyanid of potassium, strength 1 : 15. Twenty 
c.c. of clear urine is now placed in a test-tube, 
and to it is added, drop by drop, the test solu- 
tion ; on so doing, if albumin be present, an 
opalescence ensues, the density of which will 
depend upon the quantity of albumin present. 
If large quantities be present, the fluid appears 
milky, with frequently a tinge of green. The 
adding of the ferrocyanid mixture (test solu- 
tion), however, should be continued until the 
entire ten c.c. is consumed. To bring out 
the reaction more plainly, the tube should be 
everted several times, holding the thumb at 



MORBID PRODUCTS IN DISEASE. 43 

the opening, so as to prevent the escape of 
fluid. 

No. 2. Saturated Solution of Picric Acid* — 
Applied in following manner : 

Ten c.c. of a saturated solution of picric acid 
is placed in a test-glass or tube, and on it is 
gently floated twenty c.c. of clear urine. If albu- 
min be present, an opalescence immediately 
forms, density of which depending upon quan- 
tity present. To avoid errors of mistaking pep- 
tones, etc., for albumin, proceed withthe picric 
acid, and heat as described under (b\ test No. i. 

No. j. Nitric Acid. — Three c.c. of clear, 
strong nitric acid is placed in a test-glass or 
tube and on it gently floated twenty c.c. of 
clear urine. If albumin be present, an opale- 
scence ensues, density of which will depend upon 
the quantity of albumin present. The drawbacks 
to this test are two — first, an excess of nitric 
acid dissolves small quantities of albumin, and, 
second, a large quantity of urates will some- 
times produce a considerable haze. To deter- 
mine, therefore, more accurately, apply the test 
with heat, as described under [b\ test No. 2. 

* If the urine is neutral or alkaline, make acid with acetic acid 
before adding the picric acid. 

. 4 



44 DIAGNOSIS BY THE URINE. 

(6) Tests with Heat. — No. i. Picric Acid. — 
Place twenty c.c. of clear urine in a test-tube, and 
heat until it boils ; if albumin be present, it will 
precipitate out, as an excess of phosphates, how- 
ever, in a urine which is neutral or alkaline will 
do the same ; cool down the tube by plunging 
into very cold water (icy cold, if possible) ; add 
to it, now, slowly, a saturated solution of picric 
acid, using about ten c.c. ; boil again, and finally 
plunge the tube once more into cold water, and, 
if a light, medium, or dense opalescence or pre- 
cipitate is formed, it is albumin. 

No. 2. Nitric Acid. — Place twenty c.c. of clear 
urine in a test-tube, and heat until it boils ; if 
albumin be present, it will precipitate out, as 
phosphates may in this test behave as just de- 
scribed with picric acid ; plunge the tube into 
very cold water and then add a few drops of 
strong nitric acid until acid ; boil again, and 
finally cool down, as already stated, by plunging 
into very cold water. If albumin be present in 
small or large quantities, the urine shows, in 
the first instance, an opalescence, and in the 
second a decided precipitate. 

I may call attention here to what I made, 
several years ago, the subject of an article in the 



MORBID PRODUCTS IN DISEASE. 



45 



" New York Medical Journal/' that frequently 
nitric acid, and even picric, when applied in the 
ordinary way, failed to detect very small quan- 
tities of albumin, but that if after boiling the 
urines in a test-tube it was suddenly plunged 
into cold water, an appreciable show of albumin 
was seen. This I have, since 
writing that article, found to take 
place more frequently in intersti- 
tial nephritis than I then thought, 
and I am now sure that many 
times when in these cases the 
urine is reported as having no 
albumin, it is due to the cause I 
have here indicated. 

The volumetric determination 
of albumin is made as follows, 
using one of Esbach's albumin- 
ometers ; Esbach's solution is also 
to be recommended as the pre- 
cipitant, and is made by taking twenty grams 
of citric acid, ten grams of picric acid, dissolv- 
ing them in 900 c.c. of hot water, and making 
up to 1000 c.c. 

For analysis, fill the albuminometer up to U 
(mark designated on each tube) with urine ; 



Fig. 4. — Esbach's 
Albuminometer. 



46 DIAGNOSIS BY THE URINE. 

then fill to the mark R with the test solution, 
place rubber cork or thumb over the top of the 
tube, and tilt and raise again several times (do 
not shake) ; close the tube with a cork and 
leave for twelve or eighteen hours. The lines 
graduated on each albuminometer represent 
the number of grams in the 1000 c.c. of urine 
under examination, consequently the line to 
which the precipitate extends marks at once 
the quantity of albumin in iooo c.c; for ex- 
ample, precipitate extended to line marked 3, 
and patient passed 1200 c.c. in twenty-four 
hours, hence : 

iooo : 1200 : : 3 : x 
x = 3.6 gm. 

The points necessary to note in the conduc- 
tion of this process are : (1) That the urine to be 
examined is acid ; if not, make so with a few drops 
of acetic acid. (2) If great quantities of albumin 
are present, dilute with one or two volumes of 
water ; of course, the dilution must be taken 
into account in making the final calculations.* 

* Turbid urines, which are found to filter with difficulty, either should 
be shaken first with chloroform or talc powder, and then filtered, or 
else made slightly alkaline with ammonium hydrate and then filtered ; 
after either one of these procedures the tests for albumin may be 
applied ; seeing, however, that the urine is first made acid with acetic 
acid. 



MORBID PRODUCTS IN DISEASE. 47 

SUGAR. 

The presence of very small quantities of sugar 
in the urine constitutes a condition known as 
glycosuria; whereas if large quantities are 
found it is called diabetes mellitus. The former 
condition, if habitual, is unnatural, and will, if 
allowed to run on, eventuate in the more for- 
midable complaint. These diseased conditions 
of the system by no means point to diseases of 
the kidneys or urinary organs, but really to 
disease of the liver, or, rather, perverted action 
therein. Sometimes, also, a diet too exclu- 
sively saccharine or starchy in its character will 
bring about this condition in those susceptible 
to this malady. The kidney, in ridding itself 
of this morbid product, becomes irritated, and 
this irritation extends down the entire canal, 
and we thus have produced a real polyuria. 
There are three distinct varieties of this disease 
as regards grade and prognosis. In the first 
class we have a urine of high specific gravity, — 
1.030 or more, — large increase of water, and an 
increase of all the other solids. In the second 
class, a urine of even higher specific gravity, — 
1.030 to 1.060, — no increase, but often dim- 



48 DIAGNOSIS BY THE URINE. 

inished volume of water, and an increase of all 
the other solids, constituting thus a true baruria. 
In the third class of cases the urine appears 
about normal in quantity, a little high in specific 
gravity, — 1.025 to 1.030, — and there is a small 
quantity of sugar. In all cases the urine is decid- 
edly acid, and undergoes, after standing a short 
while, putrid (alkaline) decomposition ; it is also 
generally turbid, from the detritus of the urinary 
organs brought about by the irritating action 
of sugar on the mucous membranes. 

All forms of this disease are grave, but the 
first two varieties are the most formidable to 
treat, and nearly always in the young eventuate 
in an early grave. The test for sugar in the 
urine is made and applied as follows : 

1. Picric Acid Test, — This affords an ex- 
tremely simple and delicate test for sugar 
(glucose) in the urine, and has the additional 
advantage of showing at the same time if 
albumin is present ; its reaction with sugar is 
also not interfered with by the presence of 
albumin. Take ten c.c. of clear urine, and to 
it add an equal quantity of a saturated aqueous 
solution of picric acid ; boil, and, after so doing, 
while still very hot, add a few drops of caustic 



MORBID PRODUCTS IN DISEASE. 49 

potash or soda solution, making alkaline; if 
sugar be present, the color changes to a deep 
red mahogany-brown, and is not to be con- 
founded with the bright cherry-red which 
occurs in any urine when treated in this way. 

2. Heller s Test. — Take a test-tube and place 
in it two drams of urine ; if albumin is present, 
first rid the urine of it by means of heat; if, 
also, the color of the urine is dark, — which, how- 
ever, is hardly ever the case in diabetic urines, 
— first treat the urine with a little red acetate 
solution, filter the urine thus freed of its color 
and then take, as said, two drams ; add to this 
one dram of caustic soda or caustic potash 
solution, and boil ; on so doing the earthy phos- 
phates precipitate out, and if they are in large 
quantities they must be filtered out ; if not, 
their presence is disregarded. The color of 
the urine, if sugar be present, changes to a 
lemon-yellow, yellowish-brown, or blackish- 
brown, according to the quantity of sugar 
present. Add, now, a few drops of nitric acid ; 
the dark color vanishes, and in its place the 
odor of burnt sugar is given off. 

The gravimetric determination of sugar is 
effected by the use of Fehling's solution, and 



50 DIAGNOSIS BY THE URINE. 

depends for its reaction upon the power of glu- 
cose to reduce, in alkaline solutions, cupric salts 
to cuprous — viz., the suboxid Cu 2 0. If the urine 
is clear 2J\Afree from albumin, measure out care- 
fully ten c.c. ; if it is not, get rid of the albumin 
by heat, filter, and then measure carefully ten c.c. 
To this add 190 c.c. of distilled water, and fill a 
burette with the same. Carefully measure out 
ten c.c. of Fehling's solution, place in a porcelain 
basin, add forty or fifty c.c. of distilled water, and 
apply heat gently. Into this run from the 
burette, carefully, drop by drop, the diluted urine, 
and on so doing the blue solution will become 
turbid, gradually losing its color, and in its place 
will appear yellow, red, and finally a colorless 
solution. When this is attained it is evident 
that complete reduction has been effected ; to 
make sure, however, take a few drops of the 
supernatant fluid from the porcelain basin, place 
in test-tube, and add a few drops of acetic acid 
and then a little ferrocyanid of potassium 
(solution) ; if no brown coloration ensues, the 
process is completed ; if, on the contrary, you 
get this reaction, continue to run in the urine 
from burette, drop by drop, and test until the 
reaction with the ferrocyanid shows no change 



MORBID PRODUCTS IN DISEASE. 



51 




Fig. 5.— Graduated Burette. 



52 . DIAGNOSIS BY THE URINE. 

in color. To calculate result, get total quantity 
of urine passed in twenty-four hours, expressed 
in cubic centimeters ; divide this by the number 
of cubic centimeters run from the burette, and 
the quotient will be the amount of sugar 
excreted in twenty-four hours, expressed in 
grams. 

Composition of Fehling's Solution. 

Cupric sulphate, 34-64 gm. 

Sodium and potassium tartrate, 1 73 " 

Sodium hydrate, 60 " 

Distilled water, to 1000 c.c. 

Ten c.c. of this solution is reduced by 0.05 gram of sugar. 



CHAPTER V. 

COLORING-MATTERS. 

Abnormal coloring-matters appear at times 
in the urine, but, with the single exception of 
the coloring derived from blood, do not indicate 
any special form of kidney or urinary disease. 

Bile, when found in the urine, indicates 
hepatic and portal congestions, and gives to it a 
brown or greenish-yellow color. Biliary acids 
with leucin and tyrosin indicate organic dis- 
ease of the liver, generally acute yellow atro- 
phy. Bile is detected in the following manner : 
To ten c.c. of urine is added three or four c.c. 
of a solution of caustic potash of exact com- 
position — one part of potash to three of water ; 
shake, and to the mixture add an excess of 
hydrochloric acid ; if bile be present, the urine 
assumes a beautiful emerald-green color. 

Biliary acids are seldom found in any appre- 
ciable quantities, and as their detection is diffi- 
cult and the pathologic processes which cause 

53 



54 



DIAGNOSIS BY THE URINE. 



them to appear are the same as those causing 
the appearance of leucin and tyrosin, I will 
mention the tests for these latter only. Fifty 
c.c. of urine is taken and evaporated to a 
small bulk ; if leucin and tyrosin are present, 




Fig. 6.— a, a. Leucin Balls. b, b. Tyrosin Sheaves, c. Double Balls 
of Ammonium Urate. 



they will crystallize out, and may be examined 
under the microscope, leucin appearing as oily, 
circular discs floating on the water, and tyrosin 
as long, prismatic needles ; should the urine 
contain albumin, it must be first rid of this bv 



COLORING-MATTERS. 55 

using as the precipitant a solution of lead ace- 
tate, which, again, must be eliminated by pass- 
ing sulphureted hydrogen through it, and the 
filtrate finally from the lead sulphide thus 
formed is used for evaporation. 



BLOOD. 

Blood appears in the urine under various 
pathologic conditions of the system, but from 
a clinical chemic standpoint we will consider 
but two conditions in which it constitutes dis- 
ease of the urinary organs: First, when blood- 
globules or corpuscles are found; and secondly, 
when only the coloring-matter is present. The 
first condition is called hematuria and the sec- 
ond hematinuria. Blood may either come from 
the kidneys or else from the bladder, and to 
make a differential diagnosis we must consider 
the reaction, blood coagula, specific gravity, and 
microscopic appearance. Hemorrhage from the 
kidney is generally acid ; from the bladder alka- 
line. When this alkalinity is due to the presence 
of carbonate of ammonia, it is then quite certain 
the hemorrhage was from the bladder. Dark 
brown or red-brown hemorrhages point to the 



56 



DIAGNOSIS BY THE URINE. 



kidneys as the diseased organs, whereas bright 
red would indicate the bladder ; smoky, also, to 
dark brown urine points to lesions in the kidney. 
Soft clots, fresh and bright, are generally 
found in kidney hemorrhage, whereas hard, 
yellow, and sometimes colorless clots point to 
the bladder as the source of trouble. Again, 



•»> • 

Fig. 7. — Colored and Colorless 
Blood-corpuscles of Various 
Forms. 







Fig. 8. — Shriveled Blood-cor- 
puscles in Urine (Catarrh 
of the Bladder) with Numer- 
ous Lymph-corpuscles and 
Crystals of Triple Phos- 
phate. 



long and rod-shaped clots indicate hemorrhage 
from the kidney, whereas large and irregular 
masses are most probably from the bladder. 
In regard to the specific gravity, we generally 
find in kidney hemorrhage a condition of poly- 
uria ; in hemorrhage from the bladder, no poly- 
uria. Under the microscope, if the hemorrhage 



( lOLORING-MATTERS. 57 

be from the kidney, we will find blood-tinged 
kidney epithelium, and if from the bladder, 
epithelium corresponding to the same. For 
the special diseases causing this pathologic 
change in the urine the reader is referred to 
special works on this subject, as the scope of 
this treatise does not permit of my so doing. 
The detection of blood in urine is determined 
either by aid of the microscope, by which we 
can identify the corpuscles, or else by the fol- 
lowing chemic tests : 

Guaiacum Test. — Mix one c.c. of freshly pre- 
pared tincture of guaiacum with the same quan- 
tity of old oil of turpentine or ozonized ether. 
Take two drams of the urine in a test-glass, 
and pour the guaiacum and turpentine upon the 
urine ; if blood be present, between the resin- 
ous mass which precipitates out and the clear 
turpentine solution a tinge of blue will appear, 
depth of color depending upon quantity of 
blood present ; shake up the mass and it will 
form a blue emulsion. Although this test will 
answer in the majority of cases, it is always 
well to strengthen it with the one I will now 
give, which is scientifically accurate but a little 
more troublesome to execute : 



58 DIAGNOSIS BY THE URINE. 

Hernin Test. — When corpuscles are not found 
in the urine, but simply coloring-matter, apply 
this test : Take three drams of the red urine, 
boil with a concentrated solution of caustic 
potash, and take the phosphatic precipitate 
which comes down with the blood-coloring 




Fig. 9. — Hemin Crystals. 
1. Human. 2. Seal. 3. Calf. 4. Pig. 5. Lamb. 6. Pike. 7. Rabbit. 



matter (tinged red) ; dry, and mix with a few 
grains of pure chlorid of sodium ; place on 
watch-glass, add to it one or two drops of 
glacial acetic acid, placing in the mixture a 
strand of hair ; after some time hemin crystals 
crystallize out on the hair, and may be identi- 
fied by means of a microscope. 



COLORING-MATTERS. 



59 



PUS. 



Pus in the urine is always the sign of inflam- 
mation, either of the kidneys or else of the 
bladder and urinary tract. Urines containing 
pus are generally alkaline, and always so when 








Fig. io.— Deposit in Ammoniacal Urine (Alkaline Fermentation). 
a. Acid Ammonium Urate, b. Ammoniomagnesium Phosphate, c. Bac- 
terium Ureae. 



the inflammation is from the bladder ; when, on 
the other hand, pus is found in an acid urine 
recently passed, it is an indication that the inflam- 
mation is either of the kidney or else of the 
ureters. Albumin is also found in these cases, 
5 



60 DIAGNOSIS BY THE URINE. 

but in small quantity. Again, if the pus is 
from disease of the bladder, the'specific gravity 
of the urine is normal or else a little above 
normal. Urines containing pus in large quan- 
tities are thick, stringy, and contain much sedi 
ment ; the sediment may be composed of pus 
alone, or else of urates, epithelium, pus, and 
blood-globules. To differentiate these condi- 
tions, apply tests already given for blood, urates, 
and uric acid ; examine epithelium deposit under 
microscope and apply following special test for 
pus : To the sediment add a solid piece of 
caustic soda or caustic potash ; it will lose its 
color and gradually become a stringy, vitreous, 
and cohesive lump if the pus is in large quan- 
tity ; in small quantities, however, the mass 
dissolves up, and leaves a fluid which is only 
stringy and vitreous. 

Urobilin. — Urobilin is best detected when in 
urine by treating, say five c.c, with ammonia hy- 
drate, when, if in large quantity, the fluid as- 
sumes a greenish hue. The phosphates are 
now filtered from the urine, and to the filtrate is 
added a solution of chlorid of zinc, which, if uro- 
bilin be present, brings out a rose-red color 
with a greenish iridescence. 



COLORING-MATTERS. 61 

Clinical Significance. — Urobilin is the chief 
coloring a^ent of normal urine, and exists in it 
in small quantity. It is increased in quantity, 
however, in acute septic fevers, to wit : pyemia, 
pneumonia, and typhoid fever, etc. ; it is, on the 
other hand, diminished in all hydremic condi- 
tions of the blood, most notably in chlorosis, 
anemia, and hysteria. 

Indican. — Indican is found in normal urine 
in mere traces, and when in larger amounts is 
abnormal, and, by some, considered as an evi- 
dence of disease of the pancreas. 

Its presence is detected by adding to five c.c. of 
clear urine five c.c. of strong c. p. hydrochloric 
acid, to which three drops only of a solution of 
chlorinated soda have been added. The fluid, on 
this addition, if indican be present, changes to a 
more or less dark color, depth of tint being in 
proportion to the quantity of indican present. 
To make more sure, however, agitate the fluid 
with a little chloroform, which dissolves out the 
indigo formed by the above reaction and settles 
as a blue layer at the bottom of the liquid. 

Acetone. — Acetone occurs sometimes in 
normal urine in traces, but when in large 
amounts is abnormal, and constitutes a condition 



62 DIAGNOSIS BY THE URINE. 

better known as acetonuria. Its presence is de- 
tected as follows : Five c.c. of clear urine is 
treated with a few drops of a freshly prepared 
solution of the nitroprussid of sodium (strength 
i : 30). Strong ammonia is then added, and 
in a few minutes, if acetone be present, a red 
color is produced, which, on the addition of 
acetic acid, changes to a purple or violet color. 
If more accuracy is required, the urine must 
be distilled and the distillate treated as just 
described. 

Clinical Significance. — Acetone frequently 
occurs in the urine in pronounced quantity in 
high fevers ; also when a highly nitrogenous 
diet is indulged in, and toward the end of 
diabetes mellitus. 

Peptone. — Peptone does not occur in normal 
urine, and its presence by some is considered 
to be due to the disintegration of pus-corpuscles 
somewhere in the body. It is found in the 
urine in many acute and specific fevers, — in cere- 
brospinal meningitis for instance, — and may at 
times indicate whether a pleuritic effusion is 
purulent or not. Its presence in urine is de- 
tected as follows : If the urine contains albumin, 
this must first be precipitated out by acetic acid 



COLORING-MATTERS. 63 

and ferrocyanid of potassium, and to the filtrate 
must be added a solution of phosphotungstic 
acid ; on so doing a cloudiness appears immedi- 
ately or after a while, depending on the amount 
of peptone present. To urine not containing 
albumin but having much color, a solution of the 
acetate of lead is first added ; filtration is then 
effected, and to the colorless filtrate, which is 
now made acid by acetic acid, the phosphotung- 
stic acid is added. 

Ehrlich's Diazo Reaction in Typhoid 
Fever. — Although the Widal method of ex- 
amining blood in typhoid fever has recently 
somewhat eclipsed Ehrlich's test, it is well to 
know how to apply it, since in the experience 
of the writer it has on many occasions given 
him most trustworthy results. The reaction de- 
pends upon the fact that sulphanilic acid in the 
presence of nitrous acid (HN0 2 ) forms diazo- 
sulphobenzol, which, uniting with certain aro- 
matic substances occasionally present in urine, 
forms anilin colors. 

The process requires two solutions, and is 
conducted as follows : 

Solution I. — Two grams of sulphanilic acid, 



64 DIAGNOSIS BY THE URINE. 

fifty c.c. of strong c. p. hydrochloric acid, and 
1000 c.c. of distilled water. 

Solution II — One gram of sodium nitrite to 
200 c.c. of distilled water. 

In performing the test, fifty c.c. of Solution I 
is mixed with one c.c. of Solution II, and of this 
twenty c.c. is taken, placed in a test-tube, and to 
it added twenty c.c. of clear urine. Ammonium 
hydrate is now added until strongly ammoniacal, 
and if the reaction be positive, the solution 
assumes a beautiful carmin-red, which, on shak- 
ing, must also appear and slay in the foam. 

To understand its clinical significance, and 
the claims set forth by its author, I quote as 
follows from Ehrlich : 

" 1. The reaction is most commonly found in 
typhoid fever from the fourth to the seventh 
day, and thereafter, and if the reaction be absent, 
the diagnosis is doubtful. 

"2. Cases of typhoid fever characterized by 
faint reaction, and occurring only for a short 
time, may be predicted to be of very mild type. 

" 3. The reaction is occasionally noted in 
phthisis pulmonalis, but only in cases pursuing 
a rapid course toward a fatal termination. 



COLORING-MATTERS. 65 

11 4. The reaction is sometimes, but not often, 
observed in cases of measles, miliary tubercu- 
losis, pyemia, scarlet fever, and erysipelas. 

"5. In diseases unaccompanied by fever, as 
chlorosis, hydremia, diabetes, diseases of the 
brain, spinal cord, liver, and kidneys, the 
reaction is always absent." 



CHAPTER VI. 

MORBID PRODUCTS WHICH ARE PROPERLY CLAS- 
SIFIED AS URINARY SEDIMENTS AND 
URINARY CALCULI. 

URINARY SEDIMENTS. 

Organized and unorganized sediments are 
found in the urine ; the former, when present, 
constitute disease, the latter only when in abnor- 
mal amounts. Tube-casts, blood-corpuscles, 
epithelium cells, and spermatozoids are organ- 
ized ; uric acid, urates, phosphates, and oxalates, 
unorganized. Uric acid is generally in lozenge- 
shaped crystals, urates indistinctly crystalline, 
phosphates generally in distinct prismatic crys- 
tals, and oxalates in small octahedra or dumb- 
bells. 

Urinary calculi are usually composed of either 
uric acid and urates of sodium, potassium, and 
calcium, or else of phosphates and oxalates of 
calcium ; xanthin and cystin are only occa- 
sionally found. To test these calculi, pulverize, 



URINARY SEDIMENTS AND CALCULI. 67 

place a small portion on platinum foil, and 
heat over the Bunsen flame. 

1. If no residue is left, it is either uric acid, 
ammonium urate, xanthin, or cystin. To 
determine this, take a small portion, place on 
watch-glass, add a few drops of dilute nitric acid, 
and heat to dryness ; add to this a few drops of 
ammonia, and if mass changes to beautiful 
purple color (murexid test), sediment is either 




Fig. 11. — Acid Ammonium Urate Crystals. 

uric acid or urate of ammonia; if no change of 
color, the substance is xanthin or cystin. To 
determine this, take portion of original pulver- 
ized calculus, and dissolve in nitric acid on watch- 
glass ; if solution turns yellow on evaporation, 
•and leaves a residue insoluble in potassium car- 
bonate, the calculus is xanthin ; should the 
solution, however, turn brown, and leave a 
residue soluble in ammonia, it is cvstin. 



68 



DIAGNOSIS BY THE URINE. 



2. If on heating the pulverized calculus on 
platinum foil a residue is left, the calculus is 
either a urate of calcium, or else an oxalate or 
phosphate of the same. To determine this, 
dissolve the substance in hydrochloric acid (on 




Fig. i2.— A. Crystals of Cystin. B. Oxalate of Lime Crystals. 



a watch-glass) ; if it effervesces, the calculus is 
either a urate or oxalate. If the murexid test, 
gives a negative result, why then it is an oxalate. 
If on adding hydrochloric acid solution is 
attained without effervescence, the calculus is a 



URINARY SEDIMENTS AND CALCULI. 69 

phosphate, which may be further verified by 
adding to the solution a few drops of nitric acid 
solution of molybdate of ammonia, when a 
canary-yellow precipitate immediately forms. 

Calculi, when occurring in the urine, although 
indicating no direct disease of the kidneys and 
urinary apparatus, do indicate, by the particular 




Fig. 13.— Oxalate of Lime Crystals. 
a, b. Octahedra. c. Compound Forms, d. Dumb-bells. 



kind, the special diathesis which is being estab- 
lished in the system, and which, in due course 
of time, will eventuate in disease of the urinarv 
organs. Sediments, too, which precipitate out 
immediately or a short time after voiding the 
urine indicate a strong tendency to the forma- 
tion of concretions. 



CHAPTER VII. 

DIFFERENTIAL DIAGNOSIS OF CHRONIC BRIGHT'S 
DISEASE, BASED ON A CLASSIFICATION OF THE 
NORMAL ABSOLUTE, THE ABSOLUTE, AND THE 
RELATIVE ABSOLUTE OF SOLIDS AND UREA 
FOUND IN URINE WITH ALBUMIN AND WITH 
OR WITHOUT TUBE-CASTS. 

In using the term chronic Bright' s disease 
instead of chronic nephritis, I know I yield to a 
popular, but at the same time, I must say, most 
generally well-understood condition of the 
patient, if not of his organ affected. 

It is quite true that the cases described by 
Richard Bright in 1827 are not those seen by 
us to-day under the title of chronic, but rather 
belong to the acute form of the malady, which, 
in our experience, is usually a self-limited dis- 
ease, and will run its course and leave the 
patient generally without damage, provided it 
has been properly cared for. By chronic 
Bright' s disease, therefore, I wish to indicate 

a far more formidable malady — a disease which 

70 



CHRONIC BRIGHT'S DISEASE. 



71 



at times comes on most stealthily, and after 
making certain headway is beyond cure. I in- 
clude, then, under and in this category the 
large white kidney, the small granular kidney, 
the small granular and fatty kidney, and, finally, 
the amyloid or waxy kidney. 

Tube-casts. — Tube-casts are considered to 




Fig. 14. — Coarsely Fig. 15. — Acid Sodic Fig. 16. — Fig. 17. — Blood- 
Granular Casts. Urate in Cylin- Leukocyte cast, 
ders. Cast. 



be fibrinous molds of the kidney tubules, and 
they frequently are mixed with blood- or pus- 
corpuscles, granular matter, epithelial cells, 
various crystals, and oil drops. When mixed 
with the epithelial cells, they are called epithelial 
casts ; when containing oil drops, fatty casts, or 
oil casts, and when appearing as perfectly clear 



72 



DIAGNOSIS BY THE URINE. 



and transparent cylinders, having the same re- 
fractive power as urine, they are termed hyaline 
casts. 




Fig. 18.— Hyaline Casts. 



Fig. 19.— Epithelial Cast. 




Fig. 20. — Finely 

Granular 

Cast. 



pep 



& P U r^ 



Fig. 21. — Peculiar Changes 
of the Red Blood-cor- 
puscles in Hematuria. 




Fig. 22. — Crenated 
Red Blood-cor- 
puscles in Renal 
Hematuria. 



CHRONIC BRIGHTS DISEASE. 



73 



Blood-casts, as their name implies, contain 
blood-corpuscles, and are indicative of acute 
inflammation of the kidneys. 

Granular casts are those containing gran- 
ules, large or small, and are composed of 
granular matter coming either from the break- 



'Mi 




# **■ 









\6>0. 






"**& 



^^#1^ 



Fig. 23. — Deposit in Acid Fermentation of Urine. 
a. Fungus, b. Amorphous Sodium Urate, c. Uric Acid. d. Calcium Oxalate. 



ing-up of the epithelial cells and blood-cells, or 
else from the material of which the cast itself is 
composed. When of the dense and coarsely 
granular type, they are very indicative of chronic 
interstitial disease. 

Mucous casts are frequently mistaken for 



74 DIAGNOSIS BY THE URINE. 

regular tube-casts, but the absence of albumin, 
together with the other conditions of the urine to 
be elaborated, will render a mistake in diagnosis 
in these cases highly reprehensible. Hyaline 
casts, too, even in urine without albumin, are not 
ra7'e in the experience of the author ; but the 
other guides to diagnosis,' soon to be given, will 
prevent mistaking these kind of cases for true 
Bright's disease. 

Finally, cast-like formations of the urates 
may be mistaken for granular casts, as they 
bear some close resemblances to the same ; 
the rounded ends of the real tube-casts, how- 
ever, will avoid such a mistake, which very 
distinctive feature is not found in these false 
casts. 

Cases Classified According to the Abso- 
lute, the Normal Absolute, and the Rela- 
tive Absolute. — By absolute we mean the 
total quantity of solids and urea found in any 
urine, irrespective of the quantity passed. 

By normal absolute we mean the total quan- 
tity of solids and urea as contained in a normal 
elimination of urine of twenty-four hours. It 
is, therefore, the same, or nearly so, as the rela- 
tive absolute. Finally, by the relative absolute 



CHRONIC BRIGHT'S DISEASE. 75 

we mean the amount of solids and urea as 
compared with the normal absolute. 

In health the normal absolute of solids varies 
from 60 to 70 grams, and urea 30 to 35 grams ; 
the quantity of water passed also in winter 
varies from 1200 c.c. to 2000 c.c, and in sum- 
mer from 900 c.c. to 1500 c.c. ; the specific 
gravity too, according to this variation in 
quantity of urine passed, shows a range in 
winter of from 1.013 to 1.022, and in summer 
of from 1.017 to 1.030. If, however, a urine 
containing no albumin and no sugar shows an 
increase of the absolute, it is an evidence of a 
condition of baruria, generally due to excessive 
elimination of phosphates or else urea. To 
make certain, therefore, which it is, make an 
estimation of the absolute urea, and note its 
quantity ; if this be normal, then the increase 
in solids is, no doubt, due to phosphates ; should 
sugar be also present, the estimation of its 
quantity, or else of that of the phosphates, will 
give the information desired. 

The absolute without the presence of alhcmin 
is increased in conditions of the system attended 
with great loss of flesh, and is technically called 
baruria. The normal absolute, again, remains 



76 DIAGNOSIS BY THE URINE. 

constant, or increases with corresponding in- 
crease of relative absolute, in all conditions of 
congestion of the kidneys ; this condition of 
things is markedly shown in heart disease, 
where, too, albumin and tube-casts frequently 
occur. To differentiate, then, this from chronic 
Bright's disease is sometimes very difficult ; the 
history, however, of the case previous to the 
heart lesion, together with the gradual lessen- 
ing of the urine and increase of solids and urea, 
will tend to exclude chronic Bright's disease, 
which, in the experience of the author, has 
never given such a clinical picture of the urine. 

Classification of Cases. — 

I. Absolute solids, 60 to 70 grams ; with 
relative absolute, 60 to 70 grams — of which urea 
is found to be 30 to 35 grams, with relative 
absolute, 30 to 35 grams ; no albumin, no sugar, 
and no tube-casts — constitutes an absolutely 
healthy condition of the kidneys. 

II. Absolute and relative solids, sixty grams 
or more, of which urea is found to be twenty 
grams or less, with albumin, and, in those near- 
ing middle life, attended or not with appearances 
of tube-casts of only, say, the hyaline type, is a 



CHRONIC BRIGHT'S DISEASE. 77 

sign of chronic Bright' s disease. To this class 
belong the so-called functional albuminurias in 
young people, not commonly met with after 
twenty years of age, but most frequently en- 
countered about the age of puberty. In these 
cases, too, the absolute and relative absolute of 
urea is found generally to run twenty or more 
grams instead of less. 

III. Absolute and relative absolute solids, 
sixty grams or less, of which urea is found to 
be twenty grams or less, points strongly to 
some disorganization of the liver, provided no 
albumin is found. 

As a specimen of this kind of urine I append 
the following analyses of a case which, on Octo- 
ber 1, 1898, showed only 9.75 grams of urea, 
and after treatment for a month and over 
showed as follows : 

Analysis made October 26, 1898. 
Quantity of urine passed in 

twenty-four hours, . . . 1450 c.c. 
Specific gravity, . . . . .. 1.014 

Reaction, Acid. 

Albumin, None. 

Sugar, " 

Absolute solids, 48.49 gm. 

Absolute urea, 17-40 " 



78 DIAGNOSIS BY THE URINE. 

Second analysis, made November 14, 1898. 
Urine passed in twenty-four 

hours, 1 1 50 c.c. 

Reaction, Acid, 

Specific gravity, 1.02 1 

Albumin, None. 

Sugar, " 

Absolute solids, 56.26 gm. 

Absolute urea, 21.22 " 

As the patient is under treatment, there is no 
benefit derived from making a calculation as to 
the relative absolutes, which gives us only the 
physiologic action of the kidneys when they are 
under no stimulation save that of the weather. 

IV. Absolute solids, forty grams or less, of 
which urea is found to be twenty grams or less, 
without albumin^ is no sign of chronic Bright' s 
disease, but simply an evidence, generally, of 
some neurasthenic condition in which the solids 
carried to the kidneys for excretion are below 
the normal, and not that the eliminative capacity 
of the kidney is in any wise affected ; these 
cases have been described by Sir Andrew 
Clark as cases of " renal inadequacy/' but 
which, in the author's experience, seem due to 
the cause above mentioned. 

In the author's experience, when the kidneys 



CHRONIC BRIGHT'S DISEASE. 79 

are really damaged, these cases show a slight 
quantity of albumin in the urine, and also fail to 
respond so readily to a salt diet when instituted. 

This test of the salt diet is applied in the 
following manner : The patient is given thirty 
or more grains of chlorid of sodium each day, 
preferably in the form of a tablet devised by 
the author for anemia and Bright's disease, and 
manufactured by Messrs. Parke, Davis & Co., 
of Detroit, Michigan, under the name of Salt 
and Iron Tablets. Three or four of these tab- 
lets are given each day, and afterward the 
urine examined daily, when, if it be a case not 
complicated with chronic kidney lesions, the 
urine immediately shows an improvement in 
the absolute solids excreted, and frequently 
in a greater relative than calculated, showing 
thus a more concentrated urine. These neu- 
rasthenic urines are generally great in quantity, 
but very low in specific gravity. 

V. Absolute solids sixty grams or more, of 
which urea is found to be thirty or more, but in 
which the relative absolute solids are less than 
fifty grams, of which the urea is found to be 
less than twenty grams, with the slightest show 
of albumin, and with or without hyaline, granu- 
lar, and epithelial casts, are, in my experience, an 



8o 



DIAGNOSIS BY THE URINE. 



unfailing sign of chronic Bright' s disease. The 
interstitial variety of kidney degeneration most 
commonly shows this kind of urine, and begins 
in this way, but at times it becomes hard to 
determine whether it belongs to this or rather to 
the chronic parenchymatous form ; the appear- 
ance, however, of much and general edema, the 
greater quantity of albumin, and the compara- 
tive youth of the patient (between twenty-five 
and forty-five), would point to chronic paren- 
chymatous degeneration rather than to inter- 
stitial growth and contraction. As a specimen 
of the urine under these conditions, I place the 
following, taken from my case-book, from a 
gentleman under my care now for several 
years, and for whom I at regular intervals 
carefully examine the urine : 

Age of patient, fifty-four. 
Analysis made January 6, 1897. 

Quantity of urine passed in 

twenty-four hours, . . . 3480 c.c. 

Reaction, . . . 

Specific gravity, 



Albumin, . . . 
Absolute solids, 

" urea, . 

Relative absolute solids 

" " urea, 



Slightly acid. 

1. 010. 
Considerable quantity. 

81.08 gm. 

31.32 " 

46.60 " 

17.99 " 



CHRONIC BRIGHTS DISEASE. 81 

In regard to the relative solids and urea, the 
calculation has been based on the passage of 
2000 c.c. as being physiologic, which, at the time 
of the year the analysis was made, I consider 
an allowable maximum ; cold weather and 
easterly winds laden with moisture having, in 
the experience of the author, sometimes on 
healthy kidneys far more diuretic effects than the 
strong drugs we frequently give for a like pur- 
pose in diseased conditions. Since the above 
analysis represents, in this class of interstitial 
cases, probably the best phase of the disease, I 
append another, which more nearly represents 
what the general practitioner will meet with in 
regular and uncomplicated cases : 

Age of patient, over fifty years. 
Date of analysis, March 27, 1897. 
Quantity of urine passed in 

twenty-four hours, . . . 3240 c.c. 

Reaction, Slightly acid. 

Specific gravity, 1.007. 

Albumin, Very slight amount. 

Absolute solids, . . . . . 52.84 gm. 

" urea, 21.06 " 

Relative absolute solids, . . 32.59 " 
" " urea, . . 13.00 " 

Having cited, now, two cases as specimens of 



82 DIAGNOSIS BY THE URINE. 

the urine in male patients in the interstitial form 
of chronic Bright' s disease, I take again from 
my case-book an interstitial renal affection occur- 
ring in the female, and in which the urine showed 
as follows : 

Analysis made December u, 1895. 
Patient, woman fifty-five years of age. 
Quantity of urine passed in 

twenty-four hours, . . . 1560 c.c. 

Reaction, Slightly acid. 

Specific gravity, 1.018. 

Albumin, Slight amount. 

Absolute solids, 65.42 gm. 

" urea, 23.40 " 

As the quantity of solids in the urine passed 
here is a physiologic amount, no calculation as 
to the relative is necessary. The presence, 
however, of albumin regularly with this kind ol 
urine, and after thirty years of age, in the ex- 
perience of the author relegates the condition 
into one of renal degeneration, and very soon 
we note in these cases a change in the urine in 
which the solids and urea fall absolutely and 
relatively, or else the relative absolute solids 
and urea increase, thereby showing diminished 
excretion of water. As an evidence of this I 
will give two more examples of urine taken 
from this same patient, but will add that the 



CHROxMC BRIGHT'S DISEASE. 83 

patient did not die until nearly three years and 
a half had elapsed from the time at which the 
urine showed this normal passage of solids and 
urea. This is an important fact to note, since, 
in the experience of the author, the signals of 
an approaching end are to be seen by comparing 
the absolutes and relative absolutes. 

Analysis made January 11, 1896. 
Urine passed in twenty-four 

hours, , 1470 c.c. 

Reaction, Slightly acid. 

Albumin, Considerable amount. 

Specific gravity, 1.018 

Absolute solids, 61.65 gm. 

" urea, 2 3-5 2 " 

Without now giving a number of analyses 
showing a lessening of the absolutes which 
occurred, I will place for your attention one 
made six months before the patient died ; it was 
as follows : 

Analysis made October 27, 1897. 
Quantity passed in twenty- 
four hours, 1380 c.c. 

Reaction, Neutral. 

Specific gravity, 1.009 

Absolute solids, 27.26 gm. 

" urea, 8.50 " 

Relative absolute soh ds> . 29.63 " 
" " urea, . . 9- 2 3 " 



84 DIAGNOSIS BY THE URINE. 

The relative absolute solids and urea have 
been calculated on a basis of 1500 c.c. as being 
physiologic at this time of the year in Charles- 
ton, S. C. ; as it is usually warm, it being only 
during cold weather, and particularly when 
attended with easterly winds, that a maximum 
allowance to the amount of 2000 c.c. has seemed 
a proper gauge to consider within the range of 
health. 

I have said that occasionally we find in this 
kind of kidney degeneration urine showing at 
times not even a trace of albumin when the 
tests are applied in the ordinary way ; this, 
I think, is due to the extreme tenuity in which 
the albumin is held in solution. If, then, in 
these clear urines you evaporate below the boil- 
ing-point until half their bulk, or until the solids 
just begin to show on account of the abstrac- 
tion of water, then the same tests applied will 
not give negative results. 

As urines of this description I append the fol- 
lowing from a female patient who died of inter- 
stitial nephritis : 

Analysis made November 17, 1896. 
Urine passed in twenty-four 

hours, 2310 c.c. 



CHRONIC BRIGHTS DISEASE. 85 

Reaction, Neutral. 

Specific gravity, 1.004. 

Albumin, Mere trace. 

Absolute solids, 2 i-43 g m - 

il urea, 4.62 " 

Relative absolute solids, . 18.55 " 

" i( urea, . . 4.0c " 

Analysis made February 6, 1897, of urine from same 
patient : 

Urine passed in twenty- 
four hours, 840 c.c. 

Reaction, Slightly acid. 

Albumin, ... .... None by tests applied in 

the usual way. 

Specific gravity, 1-013 

Absolute solids, 25.44 gm. 

" urea, 9- 2 4 " 

Relative absolute solids, . 60.56 " 

" " urea, . . 22.00 " 

As before said, when the analyses are made 
in cold weather, 2000 c.c. must be considered 
as physiologically permissible, but during the 
winter or fall, if the weather is warm and balmy, 
a general average of 1500 c.c. will be nearer 
right on which to base the calculation of rela- 
tive solids and urea. Should the analyses be 
made in summer, in the experience of the writer 



86 DIAGNOSIS BY THE URINE. 

a minimum of 900 c.c. or maximum of 1500 c.c. 
is permissible in health. 

VI. Under this head we place those cases in 
which the absolute solids are thirty grams or less, 
and of which the urea is found to be ten grams 
or less, with relative absolute solids twenty 
grams or more and urea ten grams or more, 
with small or large show of albumin and with 
or without hyaline, granular, or epithelial casts. 
These are truly cases of chronic Bright's dis- 
ease in their last stages, which may have been 
preceded by either the amyloid kidney, the 
large white kidney, the fatty kidney, or else the 
granular or contracted kidney. As an example 
of urine of this description I append the follow- 
ing analysis : 

Analysis made October 27, 1897 ; patient, female. 
Urine passed in twenty-four 

hours, 1380 c.c. 

Reaction, Neutral. 

Specific gravity, 1.009 

Albumin, Small amount. 

Absolute solids, 27.26 gm. 

" urea, 8.50 " 

Relative absolute solids, . 29.63 " 

" " urea, . . 9.23 " 

The relative solids and urea are calculated on 



CHRONIC BRIGHTS DISEASE. 87 

a basis of 1500 c.c, but really for diagnostic 
and prognostic purposes, when the urine shows 
so low an absolute amount of solids and urea 
as in the above analysis, it is unnecessary to 
calculate what it would be to a normal excre- 
tion of solids and urine respectively. 

It may be, however, broadly stated that when 
the relative absolute solids and urea rise in the 
neighborhood of what the normal absolute ought 
to be, at the expense of the absolutes, then the 
case is very near to a close ; thus, in the case 
already cited, at which the analysis was made a 
few months prior to death, it will be seen that 
the relative absolute solids were 60.56 grams 
and the relative absolute urea 22.0 grams, 
whereas the absolute solids were 25.44 and 
urea 9.24 grams. 

I now append the result of my analyses of a 
few more specimens of urine taken from patients 
still alive, and some of whom have passed away, 
to show how long persons can live with inter- 
stitial degeneration of the kidneys, even when 
the solids and urea, absolutely and relatively, 
the one or the other, are high or low. 

Case L — Patient, male ; age about fifty, still 
alive, and apparently enjoying good health. 



88 DIAGNOSIS BY THE URINE. 

Analysis made April 24, 1895. 
Urine passed in twenty-four 

hours, 3 2 5° c - c - 

Reaction, Acid. 

Specific gravity, 1.006 

Albumin, Very slight amount. 

Absolute solids, 45-43 g m - 

" urea, 20.15 " 

Relative absolute solids, . 20.96 " 
" " urea, . . 9.60 " 

The relatives have been calculated on a basis 
of 1500 c.c. of urine as normal for this time of 
the year. It may be said of this patient that he 
has regularly taken my salt and iron tablets, 
and this analysis only represents, then, his con- 
dition before he began treatment. 

Case IL — Patient, female. 

Analyses made November 21, 1894, December 1, 1894, 
December 6, 1894, December 18, 1894. 

Analysis of November 21, 1894. 
Urine passed in twenty-four 

hours, 2240 c.c. 

Reaction, Alkaline. 

Specific gravity, 1-005 

Albumin, Little. 

Absolute solids, 26.09 g m - 

u urea, 6.72 " 

Relative absolute solids, . 23.29 " 

i( " urea, . . 6.00 " 



CHRONIC BRIGHTS DISEASE. 89 

Analysis of December 1, 1894. 
Urine passed in twenty-four 

hours, 2160 c.c. 

Reaction, Alkaline. 

Specific gravity, i-°o5 

Albumin, Little. 

Absolute solids, 25.16 gm. 

" urea, 7.53 " 

Analysis of December 6, 1894. 
Urine passed in twenty-four 

hours, I 3 2 ° c - c - 

Reaction, Acid. 

Specific gravity, . . . .. 1.010 

Albumin, Very little. 

Absolute solids, 3°-75 g m - 

" urea, . . . .,. 7.92 " 

Analysis of December 18, 1894. 
Urine passed in twenty-four 

hours, 15 00 c.c. 

Reaction, Slightly acid. 

Specific gravity, 1.012 

Absolute solids, 41 .94 gm. 

" urea, .11.10 " 

This patient died in the spring of 1898, show- 
ing at that time, and six months before, an in- 
crease of the relative absolute of solids and urea 
at the expense of the absolute, thus evidencing 
extreme dilatation of the heart. In summariz- 



90 DIAGNOSIS BY THE URINE. 

ing, then, the lessons to be taught by these 
analyses, and many more I could give, I will 
say a few words about tube-casts, since it will 
be observed that I do not state in these analyses 
whether or not I found them. This I have pur- 
posely done, as I have for a long while con- 
tended that it was, in the vast bulk of cases, 
entirely unnecessary to look for them when 
other clinical features were present in the urine, 
and which, when found, were far less mislead- 
ing than the occasional finding, say, of hyaline, 
and at times even granular, tube-casts in the 
urine of one past middle age, and in other 
respects in good health. 

What, then, are the clinical features that make 
tube-casts not misleading, and upon which we 
rely in making a differential diagnosis of chronic 
renal affections ? My answer is : First, the 
presence of albumin in the urine ; second, a 
diminution in the relative absolute solids and 
urea, with a normal quantity of solids and urea 
{not normal absolute, which refers also to nor- 
mal quantity of urine) or an excessive amount 
of absolute solids and urea ; third, an increase 
in the relative absolute solids and urea at the 
expense of the absolute. 



CHRONIC BRIGHT'S DISEASE. 91 

If, with these conditions, tube-casts are found, 
they make us doubly sure of our diagnosis, 
whereas their absence would not with us 
exclude chronic Brio-ht's disease. 

In our observations tube-casts are not found 
to any extent, unless in urine in which the above 
conditions have been fulfilled ; and when they 
are occasionally seen in urine which does not 
react as just set forth, we think chronic renal 
lesions may be excluded. 

Tube-casts have generally been divided into 
the hyaline, — broad and slender, — the granular, 
and the epithelial ; frequently, we meet with 
one and sometimes with all in chronic Bright's 
disease, and were it thus only in these affections 
that they are met with, why then we would have 
a sure means of diagnosticating Bright's dis- 
ease ; as this is not the case, however, we must 
fortify their finding with the other clinical feat- 
ures already elaborated, and which, in the ex- 
perience of the writer, has failed less often 
than when tube-casts, and especially of the hya- 
line type, were taken as evincing a disease of 
the kidney. 

Finally, there are certain fevers — and if our 
knowledge were greater, I feel sure the list 

7 



92 DIAGNOSIS BY THE URINE. 

would be much enlarged — which are attended at 
their commencing stages with symptoms which, 
by the novice, might be taken for acute, but 
hardly for chronic, Bright' s disease — to wit: an 
appearance of albumin and tube-casts. As far, 
however, as my experience goes with this class 
of cases, I am not aware that the other clinical 
features of the urine already stated are met 
with ttnless a chronic affection is coincident with 
the fever. As the fever advances, the clinical 
features of the urine are so changed that he 
would be a bold — yes, rash — diagnostician, who 
would venture an opinion as to the real state of 
the kidneys ; at the beginning of the attack, or 
else when convalescence is well established, 
should be the time to definitely determine if 
the kidneys are really diseased. 

The infective diseases are those in which 
these changes of the uriiTe are observed, and 
most markedly in the author's experience in 
pneumonia, typhoid fever, diphtheria, and 
scarlet fever ; that it occurs in some others is 
equally true, as some of the recent text-books 
used in our medical colleges will show. 

The author would also add that during the 
paroxysms of malarial fever albumin is fre- 



CHRONIC BRIGHT'S DISEASE. 93 

quently found in the urine, together with tube- 
casts and blood-corpuscles. If the paroxysms 
are not quickly relieved by proper medication, 
the albumin continues in the urine for some 
length of time, even after the patient is up and 
about. This malarial poison is, therefore, in 
my experience, a prolific cause for degeneration 
of the kidney when allowed to remain in the 
system ; and though during an attack of mala- 
rial fever one may expect frequently to meet 
with cases showing albumin and tube-casts in 
the urine, after the fever is over, if the kidneys 
are not damaged, these abnormal products 
should vanish. 

In health the normal and relative absolutes 
of solids should be either the same or range 
between sixty and seventy grams. In disease, 
however, they vary much ; as a means, then, 
for comparing these variations I append the 
following tables, and will designate them a, b, c y 
respectively, dividing these also into four stages : 



94 



DIAGNOSIS BY THE URINE. 



(a) In Health without Albumin. 

Solids. N. A. 60 to 70 gm. R. A. 60 to 70 gm. 

a 
Urea. N. A. 30 to 35 gm. R. A. 30 to 35 gm. 



(£) In Disease and with Albumin. 



Solids. 



Solids. 



A. 60 gm. or more. 
A. 50 " 
A. 40 " " 

A. 30 " " 

or else 

A. 40 gm. or less. 
A. 30 " 
A. 20 " 
A. 10 " 



R. A. 50 gm. or less. 
R. A. 40 " " 

R. A. 30 " " 
R. A. 20 " " 



R. A. 60 gm. or more. 
R. A. 45 " " 

R. A. 30 " 
R. A. 20 l < " 



(c) In Disease and with Albumin. 



Urea. 



Urea. 



A. 30 gm. or more. 
A. 20 "' " 

A. 15 " << 

A. 10 " 

or else 

A. 20 gm. or less. 

A. 15 " 

A. 10 " 

A. 5 >< 



R. A. 20 gm. or less. 
R. A. 15 << 
R. A. 10 " 
R. A. 5 " 



R. A. 30 gm. or more. 
R. A. 20 " 
R. A. 15 " " 

R. A. 7 " 



A., the absolute; N. A., the normal absolute; R. A., the relative absolute. 



CHRONIC BRIGHT'S DISEASE. 95 

On comparing these tables, then, it will be 
seen that the absolute decreases and the relative 
incr 'eases zvith albumin, with or without tube- 
casts, in the final months of chronic Bright's 
disease ; and that the absolute increases and 
the relative absolute decreases in the commenc- 
ing stages of chronic Bright's disease, and 
generally continues to do so, or may, by proper 
treatment, be made to do so, until the stage of 
dilatation of the heart is established. 

In the experience of the author a urine which, 
under strong stimulation of the kidneys, shows of 
absolute solids thirty grams or less, and relative 
absolute forty-five grams or more, is an evidence 
of the utter hopelessness of the case ; so 
long as the relative absolute can be made to 
descend and the absolute to ascend, we should 
not despair ; but so soon as the reverse is 
actually established, why then all treatment 
is of no avail, and the end must and will 
come. 

Finally, the inference drawn from the above 
tables may be succinctly stated as follows : In 
urine containing albumin : 

1. The absolute nearly what the normal abso- 
lute would be. 



96 DIAGNOSIS BY THE URINE. 

2. The absolute increased and the relative 
absolute decreased. 

3. The absolute decreased and the relative 
absolute increased. 

No. 1 represents the starting stage of chronic 
kidney lesions, and generally the so-called 
functional albuminurias begin in this way ; 
occasionally, however, even in advanced cases, by 
strong stimulation the kidneys may for a time 
show this kind of urine, but they very soon 
lapse into the third stage, and after so doing 
run the regular course, showing diminution of 
solids absolutely and increase relatively. 

No. 2 represents what is seen in the advanc- 
ing stages of kidney lesions, and may extend 
over many years. 

No. 3 is sometimes the natural consequence 
of what has preceded in No. 2, and brings us 
nearer the end of the disease. 

Inasmuch, then, as the determination of the 
normal absolute and relative absolute is, with 
us, of such importance for making a correct 
diagnosis, as well as prognosis, I will now say 
a few words as to the taking of the quantity 
and specific gravity of the urine : 

I. No urine should be collected from any 



CHRONIC BRIGHT'S DISEASE. 97 

person who is undergoing any treatment what- 
soever. 

II. If such be the case, treatment should be 
intermitted until a few days have allowed the 
medicines to pass from out of the urine. 

III. The individual should only be allowed as a 
drinking beverage rain, well, or spring water, so 
that the excreting capacity of the kidneys may 
be physiologically gauged : an allowance each 
day, in winter, of not less than three tumblerfuls 
if soup is not taken, or two if it is ; and in sum- 
mer, under the same conditions, of not less than 
six ; or four will be sufficient with a good ordi- 
nary average diet of food not excluding tea or 
coffee — one or the other at breakfast and at 
night, if that has been the custom of the individ- 
ual whose urine you are examining. Although 
these quantities represent, in our experience, a 
good average in adults of sedentary habits, 
they would have to be increased if the person 
indulged in exercise just before the examina- 
tion. 

IV. And, lastly, the specific gravity should be 
taken and solids calculated on the basis of 6o° 
F. ; and for every 5.5 increase in temper- 
ature of the urine above that, an addition 



98 DIAGNOSIS BY THE URINE. 

of one degree must be made to the reading. 
Thus, if the patient passed a urine of specific 
gravity 1.016, temperature 8o°, it would read 
1. 0196. 

Before concluding, I deem it well to say a 
few words in regard to neurasthenia in persons 
suffering from chronic Bright's disease. When 
this condition is coincident with kidney lesions 
it makes a prognosis at times very difficult, and 
it is only by repeated examinations of the urine 
that this source of error can be eliminated. 
For example, we have seen in an interstitial 
nephritis an average analysis of the urine show 
68.50 grams of absolute solids and 27.93 grams 
of absolute urea, and during a nervous con- 
dition we have seen the same urine show less 
than forty grams of absolute solids with less 
than fifteen grams of urea. Most assuredly, 
then, a prognosis based on this latter analysis 
would be misleading, and would lead us into giv- 
ing too grave a prognosis as to the immediate 
future of the patient. A continuous neuras- 
thenic affection, whether or not induced by the 
kidney lesion, is, in our experience, a grave 
complication, and will much shorten the life of 
the individual ; but a transient and occasional 



CHRONIC BRIGHT'S DISEASE. 99 

array of neurasthenic symptoms does not por- 
tend so seriously. 

Finally, as life insurance is getting to be a 
matter of great importance and everyday oc- 
currence, I shall conclude this chapter by giving 
the following rules, which, it is thought, will aid 
the examiner in avoiding bad risks and accept- 
ing those which, by the author, seem legitimate 
ones : 

Rules for Life Insurance Examiners. 

Rule I. — View with suspicion amy specimen 
of urine containing albumin, and be especially 
cautious if the specimen at the same time during 
the winter months shows a winter minimum of 
1. 01 3 specific gravity, or else during the summer 
the minimum of 1.017. 

Rule II. — Reject any urine after middle age 
containing albumin with the absolute solids and 
urea either normal or else increased and the 
relative absolutes decreased. 

Rule III. — Reject a urine showing albumin 
and a decrease of absolutes with an increase of 
relative absolutes. 

Rule IV. — Do not regard after middle acre 

o o 

the occasional finding of tube-casts, hyaline and 



ioo DIAGNOSIS BY THE URINE. 

sometimes granular, as militating against insur- 
ance if the absolutes and relative absolutes are 
normal and the urine is also free from albumin. 

Rule V. — Never report a urine free of albumin 
in which the absolutes and relative absolutes 
appear as in Rules II and III, unless you have 
evaporated the urine below boiling to a point at 
which the solids begin to precipitate out, and to 
which condensed urine you have applied the 
tests for albumin. 

The view, then, held by us as to the value to 
be attached <*to the finding of tube-casts in the 
urine, although opposed to that usually taught, 
is based upon the experience of the author, ex- 
tending over several years, with cases most care- 
fully watched. He is aware, therefore, that he 
may encounter much opposition from the pro- 
fession in accepting his experience as a guide 
for safety, and especially from examiners of 
life insurance companies, who pay, we think, far 
too much attention to the finding of tube-casts in 
those past middle age, and too little to the other 
clinical features which we have tried to clearly 
set forth as far more certain guides. We feel, 
then, that tube-casts after middle life are often 
but the expression of natural, and not of serious, 



CHRONIC BRIGHT'S DISEASE. 101 

pathologic changes going on in the kidneys, to- 
gether, we believe, with similar changes in other 
organs, with the exfoliations of which science at 
present is not sufficiently familiar. We are led 
to this conclusion from the following facts : 

First, that kind of kidney lesion attended 
with a large show of tube-casts is curable, or, 
rather, self-limited, and generally leaves the 
kidney uninjured. I refer to acute Bright's dis- 
ease. Surely, here the epithelial lining of the 
tubules is replaced, or else the kidney would 
not do its work as before the attack, which 
factor — its capability of doing its former work 
— is the only trite gauge to judge a kidney by. 

Second, that kidney lesion which is far beyond 
cure, but which sometimes extends over many 
years, is frequently attended with but few 
tube-casts. In this kidney degeneration surely 
the exfoliation of a few tube-casts can not be 
looked upon as of so serious import, or as the 
cause of the final changes found in this kidney. 
It will also be noted that their presence gives 
us no data by which to formulate a prognosis. 

This change in the cirrhotic kidney and epi- 
thelial lining of the tubules appears to us to be 
more in the way of crowding out by the con- 



102 DIAGNOSIS BY THE URINE. 

densation of kidney tissue into connective- 
tissue substance. The most fatal and short- 
lived form of kidney lesion in my experience 
has been the large white kidney. Here the epi- 
thelial lining is not only inflamed and exfoliated 
in large masses, but the entire kidney is in a 
state of subacute inflammation and congestion. 
These two processes, therefore, working to- 
gether, if not relieved, most absolutely change 
the excreting capacity of the kidney. So we 
have increased exudation of albumin from the 
continued pressure and hydremic condition of 
the blood, and also the copious appearance of 
tube-casts, due to inflammation not only of a 
chronic character, but at times of a subacute 
and even acute form, attended with fever. 

This acute exacerbation grafted on a chronic 
kidney lesion is far more often, in my experi- 
ence, met with in the large white kidney than 
in the true cirrhotic; that it may occur in this 
form of kidney lesion is no doubt true, but of 
its occurrence we have had but little oppor- 
tunity of judging. With us, too, the large 
w T hite kidney has always been far more sensi- 
tive to atmospheric changes and gastric dis- 
turbances than the cirrhotic. The possibility, 



CHRONIC BRIGHT'S DISEASE. 103 

however, of conducting by judicious treatment 
the large white kidney into the secondary and 
finally atrophic form is always to be kept in 
mind, for in so doing life may be prolonged 
and a miserable and distressing train of symp- 
toms relieved. 

Third, and lastly, the exfoliation of kidney 
tissue in the form of tube-casts is now by some 
admitted to frequently take place when toxins 
occur in the blood, and which, when eliminated, 
leave the kidney unhurt. 

With these reasons, then, for taking this 
view in regard to tube-casts, I conclude this 
chapter. 



CHAPTER VIII. 

RESUME. 

THE DIAGNOSIS OF DISEASES OF THE KIDNEY 
AND URINARY ORGANS. 

All forms of kidney degeneration are due 
to one of three causes : 

i. Hyperemia, which, when active, is called 
acute congestion, and when passive, chronic 
congestion. 

2. Irritation ; this is almost always active in 
its character, and sooner or later eventuates in 
inflammation, or else, taking a more chronic or 
subacute course, brings about those pathologic 
changes which are termed capillary arterio- 
fibrosis. 

3. Inflammation ; this, too, is either of an 
acute and active form, or else of a more 
chronic and subacute character. The causes 
or class of causes which bring about this con- 
dition of things are either direct or indirect, the 

first class inducing active inflammation and the 

104 



RESUME. 105 

second an inflammation of a more chronic 
course. 

To differentiate these several phases of kid- 
ney disease requires, at times, a good deal of 
well-directed patience and perseverance. Im- 
portant is it, however, for on the right apprecia- 
tion of the case not only depends a proper 
prognosis, but at times the very life of the 
patient itself. 

Hyperemia, whether active or passive, is not 
in itself a disease of the kidneys, but simply the 
expression of a condition which, if unrelieved, 
will eventuate in disease. The appearance of 
and morbid anatomy of the kidneys undergoing 
this process are important to us only as a 
pathologic study for future information. The 
appearance and character of the urine passed 
during this period, on the other hand, are of 
great practical use and importance, as they can 
be gathered during life, whereas the pathologic 
study begins only when life is extinct. The 
differential diagnosis between active and passive 
congestion is made as follows : 

In active congestion we have a 'complaint 
coming on suddenly ; in passive, coming on 
gradually. In active congestion the arterial sys- 



106 DIAGNOSIS BY THE URINE. 

tern is in a high state of tension ; in passive, the 
tension is low. In active congestion the urine is 
suddenly decreased in quantity or else normal, 
specific gravity normal, and little or no albumin 
in passive, the urine will be observed to have 
decreased from day to day, to contain more 
albumin, to have increased in specific gravity 
and depth of color, and to have, on standing, a 
decided sediment of the salts which precipitate 
out from the diminished volume of water. If 
this condition be allowed to continue very long, 
albumin increases to great quantities in the 
urine, and with the increase the patient becomes 
anasarcous ; if the cause of the venous stasis can 
not be removed, the case rapidly goes into neph- 
ritis of a chronic character. The time at which 
this change takes place is always marked by a 
decrease of specific gravity (under 1.018), and 
the appearance, generally, of granular and tube- 
casts. Should active hyperemia run on uncon- 
trolled, the case is more apt to develop into one 
of acute nephritis. 

The direct causes of active hyperemia are 
usually sudden variations between the surface 
and central temperatures of the body, brought 
about by chilling the body in various ways. 



RESUME. 107 

Passive hyperemia, or renal stasis, is due to 
obstructive causes, — such as occur in heart, lung, 
and liver diseases, — chronic peritonitis with effu- 
sion, hydatid tumors, pregnancy, and, in fine, to 
all sources which obstruct the direct, or else the 
return, blood-supply of the kidneys. In both 
forms of hyperemia the temperature of the 
body is not increased unless some intercurrent 
affection is also present. I may finally add that, 
as a further means of diagnosing these two con- 
ditions, the effect of diuretics and arterial tonics 
and sedatives may be made use of. 

In active congestion diuretics and arterial 
tonics which owe their diuretic action to an 
increase of the tension of the blood are 
pernicious, whereas sedatives or diuretics 
which increase the flow of urine by simply 
increasing the transudation of water are bene- 
ficial. In passive congestion, digitalis, spar- 
tein, and caffein act with efficiency and 
promptness, and lose only their effect when 
the obstruction which causes the stasis is 
permanent and increasing. 



io8 DIAGNOSIS BY THE URINE. 

PARENCHYMATOUS NEPHRITIS. 

Whether or not this pathologic condition of 
the kidneys is brought about by irritation or 
inflammation, preceded or not by acute or 
passive congestion, we recognize but two 
kinds — acute and chronic ; and, again, of the 
acute, two varieties: (i) Ordinary catarrh of 
the tubules of the kidney, similar to an ordi- 
nary catarrh of the bronchial tubes; (2) a more 
severe form of catarrh of the urine tubes, char- 
acterized by a profuse exudative secretion ; this 
is known as diffuse or croupous nephritis (acute 
Bright's disease), and would correspond, taking 
the comparison above, to a severe pneumonitis. 
The differential diagnosis is made as follows : 

In acute catarrhal nephritis we have little or 
no fever; slight bearing and dragging pains in 
the sacral region ; small show, and sometimes 
none at all, of albumin, normal or slightly 
diminished quantity of urine, specific gravity 
normal, reaction acid, usually decided sedi- 
ment, but composed mainly of mucus ; no 
edema or anasarca. 

In acute diffuse nephritis we have considera- 
ble fever, greater feeling of discomfort in sacral 



RESUME. 109 

region, much edema, and sometimes anasarca 
so great as to completely disfigure the indi- 
vidual ; large quantities of albumin in the 
urine, increased specific gravity, and marked 
diminution in quantity of water (often only 
200 c.c. in twenty-four hours); large, sedimen- 
tary deposits, composed mainly of urates, blood- 
coloring matters, and epithelial cells. 



CHRONIC PARENCHYMATOUS NEPHRITIS. 

Chronic parenchymatous nephritis may be 
the sequel of an acute attack, but oftener 
begins as such. The first symptom of this 
disease is dropsy without fever ; the specific 
gravity of the urine is always found to be below 
normal, and has a range, generally, of between 
1. 01 3 and 1. 01 7. When the specific gravity 
falls below this, and shows a lower limit of 
1. 010 or 1. 01 2, it is an evidence that the 
nephritis is taking on what may be termed a 
secondary action, and is going to become an 
interstitial variety. The quantity of urine passed 
is generally normal, its reaction decidedly acid, 
and its color is generally pale yellow. It con- 
tains much detritus, frequently consisting of 



no DIAGNOSIS BY THE URINE. 

epithelium of the kidney and various cell forms; 
albumin is always found in considerable quan- 
tities, ranging from y 2 of one to 2^ per cent. 



INTERSTITIAL NEPHRITIS. 

This disease of the kidneys is frequently a 
natural consequence of the chronic secondary 
parenchymatous variety ; when it is, the general 
characteristics are somewhat masked, as the 
change has been gradual. The great difference, 
however, shown in the urine is in the smaller 
quantity of albumin, the increased volume, 
paler color, and specific gravity ranging lower 
— 1.008 to 0.012. After a little, we note the 
fibrous change the vascular system has under- 
gone, and see" developed a true capillary 
arteriofibrosis, evidenced by a full, tense pulse, 
associated with hypertrophy of the heart — most 
apparent on the left side. Interstitial nephritis, 
or cirrhosis of the kidney, seldom starts in 
youth, but most often about the middle of life, 
and without dropsy. For a long time there is 
really nothing to call attention to the disease, 
save the condition of the heart and pulse. If, 
however, together with this indication we find 



RESUME. in 

small (yes, sometimes very small, and for days 
at a time none) quantities of albumin, impair- 
ment of vision, diminished specific gravity, and 
a pale-colored urine of normal quantity or else 
increased, we can safely pronounce the case as 
one of atrophy of the kidneys. It is particu- 
larly important in these cases to estimate the 
urea from time to time, as a means of better 
forming a diagnosis and prognosis. 

As the disease advances, although the volume 
of water increases the urea falls off, and toward 
the end seldom shows more than seven or eight 
grams for the twenty-four hours. The reaction 
of the urine in this variety of kidney disease is 
acid, and only becomes neutral and alkaline 
when the nephritis is of the suppurative variety; 
when of this latter kind, the odor of the urine 
is putrid, and it contains blood-coloring matters 
and pus. 

The differential diagnosis between interstitial 
nephritis and amyloid kidney is extremely 
difficult, as the general characteristics of the 
urine are about the same. Amyloid kidney, 
however, has no symptoms of capillary arterio- 
fibrosis, and is generally associated with some 
constitutional disease, such as chronic tubercu- 



H2 DIAGNOSIS BY THE URINE. 

losis, scrofula, malarial cachexia, and syphilis, 
and is frequently accompanied with a certain 
amount of dropsy. 



PYELITIS AND CYSTITIS. 

Inflammation of the pelvis of the kidney and 
of the ureters and bladder frequently occurs. 
Though much has been written in regard to the 
differential diagnosis of these conditions, it is of 
no real practical utility, since a cystitis will, if 
not cured, set up inflammation higher up the 
canal, and vice versa. For practical clinical 
purposes, therefore, I will disregard much of 
this, and will say that when the pelvis of the 
kidney and the ureters are alone affected it is 
called pyelitis ; when, however, the inflamma- 
tion extends to the bladder, it is called cystitis. 
If the pelvis of the kidney is the principal seat 
of inflammation, it is designated as cysto- 
pyelitis ; if, on the other hand, the bladder is the 
center of inflammation, it is called pyelocystitis. 
These inflammations may be acute or chronic, 
but in all we find pus. A differential diagnosis 
is approximately made as follows : 

Acute and chronic inflammations of the pelvis 



KKSUME. 



"3 



of the kidney and ureters are attended with 
acid urines, albumin, and pus; acute inflamma- 
tions of the bladder, with neutral or alkaline 
urine, pus, but no albumin. 




Fig. 24. — fa) Epithelial Cells from the Male Urethra; {b) from the 
Vagina; (o from the Prostate; (d) Cowper's Glands; (<?) Littre's 
Glands; (/') Female Urethra; {g) Bladder. 



Inflammation of the pelvis and ureters is 
accompanied by polyuria ; inflammation of the 
bladder, never. Specific gravity in pyelitis is 
generally below normal ; specific gravity in 



ii 4 DIAGNOSIS BY THE URINE. 

cystitis, normal or above. No particular fre- 
quency in making water in pyelitis ; constant 
desire to pass water in cystitis. Besides these 
differential points, the microscope may be used 
for the identification of renal or else of bladder 
epithelium, as the case may be. 

Should the cystitis, as is sometimes the case, 
be very severe, we will then find not only pus, 
but albumin in the urine. To differentiate this 
from pyelitis, we must refer to the specific 
gravity and reaction : In pyelitis it is generally 
below normal, and reaction acid or just neutral ; 
in cystitis (severe), specific gravity is normal 
or above, and reaction intensely alkaline, due to 
presence of ammonia carbonate, and occasionally 
to ammonium sulphid. In doubtful cases the 
urine must be drawn for examination, by means 
of a rubber catheter, directly from the kidney, 
guttatim* 

* In all urine examinations the entire quantity for twenty-four hours 
should be known, and a portion of this taken for analysis. In case this 
provision can not be carried out, the urine passed on rising in the morn- 
ing will give the best approximate results. One gram is equivalent to 
15.44 grains ; thirty c.c. are equivalent to one ounce. 

If specimens of urine have to be sent for examination from a dis- 
tance, first measure the quantity for the twenty-four hours ; then take 
its specific gravity, and to six ounces of the mixed urine add one tea- 
spoonful of Squibb's chloroform, and send the same for analysis. The 
addition of the chloroform keeps the urine from fermenting. 



RESUME. 115 

Apparatus required for executing all the tests contained 
in this volume : 

1. Test-tubes, one dozen. 

2. Small funnels — y^ of an ounce, 6 ; four ounces, 6. 

3. Glass rods, different sizes, 6. 

4. Watch-glasses, 6. 

5. One nest of beakers. 

6. One wash-bottle, twelve ounces, for water. 

7. Porcelain evaporating dishes, 6. 

8. Small conic test-glasses, 6. 

9. Water-bath. 

10. Spirit-lamp. 

11. Small piece platinum foil. 

12. One pair of pincers. 

13. Small chemic balance (only necessary, however, if 

gravimetric estimations are to be made). 

14. One urinometer float (with temperature chart). 

15. Microscope with appurtenances. 

16. One Esbach's albuminometer. 

17. One Doremus' ureometer. 

18. One Mohr's burette, fifty c.c, graduated in tenths. 

19. Two sizes cut filter-paper for funnels, as stated. 

20. Blue and red litmus-paper. 

21. One liter flask. 

22. One 200 c.c. flask. 

23. One 10 c.c. pipette. 

24. One measuring jar for measuring urine, to hold ninety 

c.c. and graduated in -^ of a c.c. divisions. 

25. One-half dozen flasks ; sizes, four and six ounces. 

26. Small quantity assorted glass tubing. 



n6 DIAGNOSIS BY THE URINE. 

27. Three or four feet india-rubber tubing. 

28. One pipette, to deliver five c.c. 

29. One-eighth gross assorted corks. 

30. Filter stand, test-rack stand, and ring stand. 

Chemicals required for executing all the tests in this 
volume : 
t. Water, distilled, or very pure rain-water. 

2. Alcohol, methylated, for lamp. 

3. Old oil of turpentine. 

4. Ozonized ether. 

5. C. p. hydrochloric acid. 

6. C. p. sulphuric acid. 

7. Picric acid, solution six grains to the ounce of water. 

8. Glacial acetic acid. 

9. Ordinary acetic acid (sp. gr. 1.04 to 1.045). 
10. Potash and soda in sticks. 

n. Potash in solution (strength, one part to three parts 

H 2 0). 

12. Rochelle salts. 

13. Cupric sulphate. 

14. Ammonia molybdate. 

15. Silver nitrate solution (one part of AgN0 3 to eight of 

water) . 

16. Citric acid. 

17. Ammonia. 

18. Lead acetate solution (1 : 8 of water). 

19. Sodium hyposulphite. 

20. Ammonium nitrate. 

21. Solution of bromin. 



RESUME. 117 

22. Ferrous stilphid. 

23. Potassium ferrocyanid. 

24. Freshly prepared tincture of guaiacum. 

25. C. p. sodium chlorid. 

26. C. p. nitric acid. 

27. Sodium nitroprussid. 

28. Chlorid of zinc. 

29. Phosphotungstic acid. 

30. Sulphanilic acid. 

31. Sodium nitrite. 

32. Solution chlorinated soda. 

The reagents used, unless stated otherwise, are solutions 
in water (1 : 15). 



n8 



DIAGNOSIS BY THE URINE. 



TABLE FOR CALCULATING THE ABSOLUTE SOLIDS 

IN URINE OF SPECIFIC GRAVITIES RANGING 

FROM 1.004 TO 1.030. 



Column 


A. 


Column B. 


Multiply by Number 


of Cubic Centi- Mu 


ltiply by Number of 


Fluidounces 


meters of Urine 


Passed in < 


if Urine Passed in Twenty-four 


Twenty-four 


Hours. 


Hours. 




Sp. gr. I.004 


O.00932 S 


p. gr. I.004 


O.2796 






1 I.005 


0.001165 * 


' " 1.005 


0.3495 






< I.006 


0.01398 


' " I.006 


O.4194 






* I.007 


0.01631 ' 


' " 1.007 


O.4893 






' I.008 


0.01864 * 


1 " I.008 


5592 






1 1 .009 


O.02097 ' 


' " I.009 


O.629I 






< 1. 010 


0.02330 ' 


' " 1. 010 


O.6990 






' I. on 


O.02563 ' 


1 " 1. on 


O.7689 






* 1. 012 


O.02796 ' 


1 " 1. 012 


o.?>^ 






1. 013 


O.03029 ' 


< " 1. 013 


0.9087 






' 1. 014 


O.03262 « 


' " 1. 014 


0.9786 






' 1.015 


0.03495 


< •< 1. 015 


1.0485 






' 1.016 


0.03728 ' 


< " 1. 016 


1.1184 






' 1. 017 


O.03961 * 


' " 1. 017 


I. 1883 






1. 018 


0.04194 ' 


< " 1. 018 


1.2582 






1 1. 019 


O.04427 * 


' " 1. 019 


1.3281 






1 1.020 


0.04660 ' 


( " 1.020 


1.3980 






* 1. 021 


O.04893 


1 " 1. 021 


1.4679 






' 1.022 


0.05126 ' 


' li 1.022 


1.5378 






1.023 


0.05359 


< " 1.023 


1.6077 






4 1.024 


O.05592 ' 


1 <4 1.024 


1.6776 






1.025 


O.05825 


' " 1.025 


1-7475 






' 1.026 


0.06058 * 


1 " 1.026 


1. 8174 






' 1.027 


0.06291 ' 


1 " 1.027 


1.8873 






1.028 


0.06524 ' 


' " 1.028 


1.9572 






1 1.029 


0.06757 


c " 1.029 


2.0271 






1.030 


0.06990 * 


1 " 1.030 


2.0970 



RESUME. 119 

To determine the quantity of solids, expressed 
in grams, multiply the number of cubic centime- 
ters of urine passed in twenty-four hours by the 
figures found in Column A corresponding to the 
specific gravity of the urine under examination, 
and the result of such multiplication will repre- 
sent the number of grams excreted. If the cal- 
culation is to be made from the fluidounces of 
urine voided, multiply the number of fluidounces 
of urine passed in twenty-four hours by the 
figures in Column B corresponding to the specific 
gravity of the urine examined, and the result 
will express the solids, in grams also. 



STATEMENTS OF THE RESULT OF A COMPLETE 
ANALYSIS OF URINE. 

Analysis, No. Date, 

Patient's Name, 

Urine Passed in Twenty-four Hours, 

Reaction, 

Specific Gravity, 

Color, Odor, 

Consistence, Transparency, 

Albiunin. — Very much — Considerable — Slight — Trace — 
None. (Erase those words not expressing.) 



120 DIAGNOSIS BY THE URINE. 

Sugar. — Very much — Considerable — Slight — Trace — 
None. (Erase those words not expressing.) 

Absolute Solids, grams. 

1 ' Urea, < < 

Relative Absolute Solids, " 

" " Urea, < < 

Chlorides. — Normal — Increased — Diminished. (Erase 
condition not found.) 

Phosphates. — Normal — Increased — Diminished. (Erase 
condition not found.) 

Uric Acid. — Normal — Increased — Diminished. (Erase 
condition not found.) 

Detritus. — Urates — Bladder cells — Kidney cells — Ureth- 
ral cells — Vaginal cells. (Erase those not found.) 

Coloring-matters. — Urobilin — Acetone — Indican — Pep- 
tone — Bile — Leucin — Tyrosin . 

Blood. — Red corpuscles — White corpuscles — Pus — Mucus. 
(Erase those not found.) 

Tube-casts. — Hyaline — Epithelial — Granular — Epithelial 
or Hyaline with Oil drops — Mucous casts — Urate 
cylinders — Urate casts simulating tube-casts. (Erase 
those not found. ) 
Extra sedimentary deposits in a calculus, what vari- 
ety? 

Ehrlich's typhoid test. 



INDEX 



Acetic acid, 50 
Acetone, 61 
Acidity of urine, 17 
Acute nephritis, 70, 106 
Albumin, composition of, 41 

detection of, in urine, 41, 48 
by acetic acid and 
ferrocyanid of po- 
tassium, 41 
by nitric acid, 43 
by picric acid, 43, 

48 

in urine, 30, 41 

volumetric determination of, 

45 
by Esbach's albu- 
minometer, 45 
Alkaline phosphates, 37 

urine, 23-25 
Ammonia carbonate, 24, 113 
Ammonium sulphid, 1 13 
Amount of urine in disease, 18 
Amyloid kidney, 86, III 
Anuria, 18 
Apparatus, 114-116 
Atrophy of kidneys, 21, 86, III 
Average composition of urine, 9 
quantity of urine in health, 
II 



Baruria, 48, 75 
Bile in urine, 53 

to detect, 53 



Biliary acids, 53 
Blood-corpuscles, 55, 56, 66, 73 
Blood in urine, 55 

detection of, 57 

differential diagnosis of, 

55 

guaiacum test for, 57 

hemin test, 58 
Brick-dust deposit, 32, 66 
Bright' s disease, 70 

cases classified, 74 



Caffein, 107 

Calcium, 32, 68 

Capillary arterio-fibrosis, 104, no 

Carbonate of ammonia, 24, 113 

Chlorid of sodium passed, 35 

Chlorids, 35 

to determine quantity, 36 
Chronic interstitial nephritis, 80 
parenchymatous nephritis, 80, 
100 
symptoms of, 80 
Chyluria, 20 

Cirrhosis of kidney, 71, 101, no 
Color of normal urine, 16, 20 
Coloring- matters of urine : bile, 
53; blood, 53 ; leucin, 53; 
tyrosin, 53 
Conditions governing excretion of 

urea, 26, 27 
Congestion of kidneys, 76, 104 
active, 104 



121 



122 



INDEX. 



Congestion of kidneys, differential 
diagnosis of, 71, 104 
passive, 104 
Consistence of urine, 16 
Constituents of urine in disease, 

10, 18 
Cupric salts, 50 
Cuprous oxid, 50 
Cystin, 66 
Cystitis, 112 
Cystopyelitis, 112 



Deviations in color of urine, 20 

in composition of urine in 
disease, 26 
Diabetes, 18 

insipidus, 19 

mellitus, 19, 20, 38, 47 

phosphatic, 38 
Differential diagnosis of chronic 

Bright's disease, 70 
Digitalis, 107 



Earthy phosphates, 37 
Ehrlich's diazo reaction in typhoid 

fever, 63 
Estimation of urea, 28 



Fehling's solution, 49, 52 

composition of, 52 
Ferrocyanid of potassium, 50 
Fixed alkali, 24 
Forms of uric-acid crystals, 33 



Glucose, 48 
Glycosuria, 47 
Gout diathesis, ^^ 
Graduated burette, 51 
Granular casts, 73 
Guaiacum, 57 



Hematinuria, 55 
Hematuria, 55 
Hemin, 58 
Hemorrhage, bladder, 55 

kidney, 55 
Hydrate solution, 29 
Hydruria, 18 
Hyperemia, 70, 71, 104 

active, 70, 105 

means of diagnosing, 71 

passive, 70, 105 
Hypobromite of soda, action of, 

28 
Hyposulphite of sodium, 23 



Indican, 61 

Inflammation of bladder, 1 12 

of kidneys, 70, 73 

of pelvis, 104, 112 

of ureters, 112 
Interstitial nephritis, 1 10 
Irritation of kidneys, 47, 70, 104 



Kidney degeneration, forms of, 

71, 93. io 4 

Kidneys, evidence of disease in, 

27 
Kreatinin, 28 



Leucin, 54 

test for, 54 
Litmus-paper, blue, 24 

red, 24 
Liver, evidence of disease in, 27, 
47 



Molybdate of ammonia, 39, 69 

nitric acid solution of, 39 
Mucous casts, 73 
Murexid test, 34, 67 



INDEX. 



123 



Nephritis, 32, 35, 70, 106 

acute, 70, 106 

catarrhal, 108 
diffuse, 108 

chronic, 70, 106 

parenchymatous, 108 
Neurasthenia, 98 
Nitrate of ammonia, 38 

of silver, 36 
Nitrogen in urine, 31 
Normal urine, 16 



Odor of urine, 17, 22 
Oliguria, 18 



Parenchymatous nephritis, 80, 

108 
Peptone, 62 
Phosphates, alkaline, 38 

earthy, 37 
Phosphatic diabetes, 20, 38 
Phosphaturia, 20, 38 
Phosphoric acid, amount passed, 

37 

gravimetric determina- 
tion of, 38 
to determine quantity of, 

37 
Platinum foil, 67 
Pneumonia, 35 
Polyuria, 18,47, 5 6 > ^3 
Potassium, 32 
Pus in urine, 59 

test for, 60 
Pyelitis, 112 
Pyelocystitis, 1 12 

Quantity of urea excreted, 26, 31 
of urine in summer, 12 

Reaction of urine, 17, 33 
Renal stasis, 107 



Sodium, 32 

hyposulphite of, 23 
Solids excreted in urine, 13, 74 
Spartein, 107 

Specific gravity of urine, 12, 19 
Statements of the result of a com- 
plete analysis of urine, 119 
Suboxid of copper, 50 
Sugar, 47 

gravimetric determination of, 

49 
Heller's test, 49 
picric acid test, 48 
presence of, in urine, 47 
test for, in urine, 48 



Temperature of urine, 15 
Transparency of urine, 17, 22 
Tube-casts, 66, 71, 90 
Turpentine, 57 
Tyrosin, 54 

test for, 54 



Urates, 28 
Urea, 26, 74 

conditions governing excre- 
tion of, 26, 27 
estimation of, 28 
quantity of, excreted, 26, 31 
Ureometer, 28 
Uric acid, 23, 28, 32 

to detect, 34 
Urina potus, 18 
Urinary calculi, 66 

murexid test of, 67 
to test, 67 
organs, disease in, 17, 18 
sediments, 66 

organized and unorgan- 
ized, 66 
Urine, what it is, 9 
alkaline, 23-25 



I2 4 



INDEX. 



Urine, average composition of, 9 
quantity in winter in 
health, II 

chlorids in pathologic, 36 

consistence of, 16 

constituents in disease, 10, 18 

deviations in color of, 20 

in composition of, in 
disease, 26 

in disease, 18 

amount of, 18 

normal, 16 

acidity of, 17 
color of, 16, 20 
odor of, 17, 22 
reaction of, 17, 23 
transparency of, 17, 22 



Urine, solids excreted in, 74 

specific gravity of, 12, 19 

temperature of, 15 

total solids in, 19 
Urobilin, 60 
Uroerythrin, 21, 32, 34 

to determine presence of, 34 



Venous stasis, 106 
Volatile alkali (carbonate of am- 
monia), 24 



Xanthin, 66 



•MB 6 1899 



t. 



LIBRARY OF CONGRESS 




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